Kelley Saia

Prenatal Buprenorphine Versus Methadone Exposure and Neonatal Outcomes: Systematic Review and Meta-Analysis

Increasing rates of maternal opioid use during pregnancy and neonatal withdrawal, termed neonatal abstinence syndrome (NAS), are public health concerns. Prenatal buprenorphine maintenance treatment (BMT) versus methadone maintenance treatment (MMT) may improve neonatal outcomes, but associations vary. To summarize evidence, we used a random-effects meta-analysis model and estimated summary measures of BMT versus MMT on several outcomes. Sensitivity analyses evaluated confounding, publication bias, and heterogeneity. Subjects were 515 neonates whose mothers received BMT and 855 neonates whose mothers received MMT and who were born from 1996 to 2012 and who were included in 12 studies. The unadjusted NAS treatment risk was lower (risk ratio=0.90, 95% confidence interval (CI): 0.81, 0.98) and mean length of hospital stay shorter (-7.23 days, 95% CI: -10.64, -3.83) in BMT-exposed versus MMT-exposed neonates. In treated neonates, NAS treatment duration was shorter (-8.46 days, 95% CI: -14.48, -2.44) and morphine dose lower (-3.60 mg, 95% CI: -7.26, 0.07) in those exposed to BMT. BMT-exposed neonates had higher mean gestational age and greater weight, length, and head circumference at birth. Fewer women treated with BMT used illicit opioids near delivery (risk ratio=0.44, 95% CI: 0.28, 0.70). Simulations suggested that confounding by indication could account for some of the observed differences. Prenatal BMT versus MMT may improve neonatal outcomes, but bias may contribute to this protective association. Further evidence is needed to guide treatment choices.

Somali immigrant women's perceptions of cesarean delivery and patient-provider communication surrounding female circumcision and childbirth in the USA.

To explore perceptions of cesarean delivery and patient–provider communication surrounding female circumcision and childbirth through interviews with Somali women residing in the USA.

Caring for Pregnant Women with Opioid Use Disorder in the USA: Expanding and Improving Treatment.

Purpose of the ReviewOpioid use disorder in the USA is rising at an alarming rate, particularly among women of childbearing age. Pregnant women with opioid use disorder face numerous barriers to care, including limited access to treatment, stigma, and fear of legal consequences. This review of opioid use disorder in pregnancy is designed to assist health care providers caring for pregnant and postpartum women with the goal of expanding evidence-based treatment practices for this vulnerable population.Recent FindingsWe review current literature on opioid use disorder among US women, existing legislation surrounding substance use in pregnancy, and available treatment options for pregnant women with opioid use disorder. Opioid agonist treatment (OAT) remains the standard of care for treating opioid use disorder in pregnancy. Medically assisted opioid withdrawal (“detoxification”) is not recommended in pregnancy and is associated with high maternal relapse rates. Extended release naltrexone may confer benefit for carefully selected patients. Histories of trauma and mental health disorders are prevalent in this population; and best practice recommendations incorporate gender-specific, trauma-informed, mental health services. Breastfeeding with OAT is safe and beneficial for the mother-infant dyad.SummaryFurther research investigating options of OAT and the efficacy of opioid antagonists in pregnancy is needed. The US health care system can adapt to provide quality care for these mother-infant dyads by expanding comprehensive treatment services and improving access to care.

Opioid addiction in pregnancy.

The purpose of this review is to discuss the incidence, risks, pregnancy complications, and maintenance options for treatment of opioid addiction in pregnancy. Summary: Opioid dependence in pregnancy carries clear identifiable maternal and fetal risk. Providing care for patients with dependence is best done in a multidisciplinary care model addressing the particular needs of this population. There are limited data on maternal detoxification, with data still emerging surrounding the safety profile of this practice. Historically, methadone has been the recommended maintenance treatment; however, recent data on buprenorphine identify this as a safe and effective option. The majority of births from women with opioid dependence result in neonatal abstinence syndrome requiring prolonged neonatal hospitalization. Intrapartum pain management should not differ from the general obstetric population. Postpartum pain is magnified in this population, and particular attention should be focused on this issue. Breast-feeding is recommended regardless of maintenance dose, unless other conditions restricting breast-feeding are present. Comprehensive postpartum care and transition of care to addiction specialists are highly recommended. Target Audience: Obstetricians and gynecologists, family physicians, addiction specialists Learning Objectives: After completing this CME activity, physicians should be better able to assess the treatment options available to patients with opioid addiction during pregnancy, compare the risk/safety profiles of methadone and buprenorphine, and evaluate the recommendations and current data surrounding breast-feeding while on opioid maintenance treatment.

Postpartum changes in methadone maintenance dose

The optimal approach to postpartum dosing among women treated with methadone maintenance is unclear. We examined doses among 101 methadone-maintained pregnant women 2, 6 and 12 weeks postpartum, and compared the incidence of having doses held for oversedation during pregnancy and postpartum. The average dose at delivery was 83.3mg, and the mean change from delivery to 12 weeks postpartum was -3.7 mg (95% CI -6.3, -1.1). The incidence of oversedation events per 10,000 days was 2.8 among pregnant women and 5.6 for postpartum women (incidence rate ratio [IRR] 2.04, 95% CI 0.66, 6.28). After adjusting for benzodiazepine prescriptions, the IRR of an oversedation event among postpartum women compared to pregnant women was 1.74 (95% CI 0.56, 5.30). In conclusion, postpartum dose changes were small in a methadone clinic using clinical assessments to determine dose. Although the incidence of oversedation events remained low postpartum, the clinically important but not statistically significant increase in events among postpartum women and those prescribed benzodiazepines requires further research. While there are not yet adequate data to support pre-specified postpartum dose reductions, the findings suggest that more frequent clinical assessments continuing as late as 12 weeks postpartum may be warranted.

Comparison of Post-Cesarean Section Opioid Analgesic Requirements in Women With Opioid Use Disorder Treated With Methadone or Buprenorphine

Objective: Buprenorphine is a highly effective treatment for opioid use disorders, but its continuation in the perioperative setting remains controversial, unlike the accepted practice of perioperative methadone continuation. Methods: We conducted a retrospective cohort study from 2006 to 2014 comparing post-cesarean section opioid analgesic requirements of women with opioid use disorders treated with methadone or buprenorphine. Preoperative, intraoperative, and postoperative opioid requirements (morphine equivalent dose [MED]), postoperative complications, and length of stay were compared between the methadone and buprenorphine groups. Results: During the 9-year study period, there were 185 women treated with methadone (mean dose 93.7 mg, SD 2.6) and 88 women treated with buprenorphine (mean dose 16.1 mg, SD 7.8). There were no statistically significant differences in MED requirements in the methadone versus buprenorphine groups: preoperative MED (11.4 mg [SD 31.5] vs 20.0 mg [SD 15.1]; mean difference [MD] 8.6, 95% confidence interval [CI] −1.9, 19.1), intraoperative MED (3.5 mg [SD 6.6] vs 5.2 mg [SD 13.7]; MD 1.8, 95% CI −1.1, 4.6), and postoperative MED during hospitalization (97.7 mg [SD 65.6] vs 85.1 mg [SD 73.0]; MD −12.6, 95% CI −31.1, 5.8). There were no statistically significant differences in postoperative complications or length of stay. Conclusions: Our study suggests that buprenorphine treatment will not interfere more than methadone with pain management after a cesarean section with no significant differences in opioid analgesic requirements, postoperative complications, or length of hospital stay. Future studies should investigate the generalizability to other surgeries.

Revision of Breastfeeding Guidelines in the Setting of Maternal Opioid Use Disorder: One Institution's Experience.

Breastfeeding is recommended for women with opioid use disorder who are treated with methadone or buprenorphine. Infants with neonatal abstinence syndrome (NAS) secondary to in-utero opioid exposure have unique challenges related to breastfeeding but also have significant benefits including improved NAS symptoms with a decreased need for pharmacotherapy. Poor understanding of substance use disorder and treatment, lack of evidence-based recommendations, and vague guidelines from national academies create controversy about breastfeeding eligibility for these women. Defining breastfeeding guidelines is often difficult, particularly in large institutions with multiple providers caring for the mother–infant dyad. Based on the available evidence and review of our institutional data, we revised our breastfeeding guidelines for mothers with opioid use disorder. The aims of our new guidelines are (a) to safely promote breastfeeding in all mothers with opioid use disorder who are in recovery, (b) to improve NAS outcomes through use of breastfeeding as a key nonpharmacologic treatment modality, and (c) to improve staff communication and consistency on the subject of breastfeeding in this patient population.

The comparative safety of buprenorphine versus methadone in pregnancy—what about confounding?

Preferential treatment of high-risk opioid-dependent pregnant women with methadone limits evidence of the comparative safety of buprenorphine versus methadone on infant outcomes. Adjustment for maternal characteristics that affect both treatment choices and birth outcomes is necessary to provide valid estimates of the effect of prenatal opioid agonist therapy exposure.

Childhood Health and Development in a Cohort of Infants Exposed Prenatally to Methadone or Buprenorphine

Background: Neonatal Abstinence Syndrome (NAS) due to in-utero opioid exposure is a growing problem with largely unknown long-term childhood outcomes. The objective of this study was to compare long-term outcomes of infants exposed to methadone versus buprenorphine in-utero. Method: This retrospective cohort study included all pregnant women on buprenorphine or methadone and their infants born between 2006-2010 at our institution. Inpatient data was merged with outpatient data from 2006-2014 for those infants who continued to receive their paediatric care at our institution. We estimated unadjusted risk ratios (RR) of the following outcomes in buprenorphine versus methadone exposed infants: 1) routine healthcare visits, 2) growth and feeding disorders, 3) developmental delay, 4) visual problems, 5) hearing problems, 6) behavioural/attentional problems. Results: Of 338 infants, 73.1% (N=247) continued to be followed at our hospital. The mean length of follow-up was 25.7 months (95% CI 22.9, 28.9). Infants in the buprenorphine group were less likely to be seen for hepatitis C exposure (19.6 vs. 9.2%, RR=0.60, 95% CI 0.40, 0.91) and more likely to have had a routine weight check (RR=2.14, 95% CI 1.05, 4.34). There were no differences in the incidence of developmental delay, ophthalmologic abnormalities, hearing deficits, or behavioural diagnoses between the groups. Results are limited by small sample size and lack of adjustment for confounders. Conclusion: No significant differences in paediatric outcomes at 2 years of age after in-utero methadone or buprenorphine exposure were found, but the evidence is affected by study limitations. Further studies in a large patient population are warranted.

Perinatal Transmission of Hepatitis C Virus: Defining the Cascade of Care

Objectives The US National Viral Hepatitis Action Plan calls for major efforts to expand hepatitis C virus (HCV) diagnosis and treatment; prenatal care settings are potential venues for expanding HCV testing. We aimed to characterize the HCV diagnostic cascade for women and infants and investigate factors associated with linkage and follow‐up. Study design We used electronic health records for a 10‐year cohort of 879 women with opioid use disorder from an obstetric clinic serving women with substance use disorders. Results Altogether, 744 women (85%) were screened for HCV; 510 (68%) were seropositive, of whom 369 (72%) had nucleic acid testing performed and of these 261 (71%) were viremic. Of 404 infants born to HCV‐seropositive women, 273 (68%) were tested at least once for HCV, 180 (45%) completed the American Academy of Pediatrics‐recommended perinatal HCV screening, and 5 (2.8%) were diagnosed with HCV infection and linked to care. More recent delivery date (2014‐2015) was associated with maternal linkage to care (aOR, 2.5; 95% CI, 1.4‐4.7). Maternal coinfection with HIV (aOR, 9.0; 95% CI, 1.1‐72.8) and methadone maintenance therapy, compared with buprenorphine (aOR, 1.5; 95% CI, 0.9‐2.5), were associated with higher rates of infant HCV testing. Conclusions HCV prevalence among pregnant women with opioid use is high and infant HCV screening is imperfect. Programmatic changes to improve both mother and infant follow‐up may help to bridge identified gaps in the cascade to cure.