Loretta P Finnegan

OPIOID DEPENDENCE DURING PREGNANCY Effects and Management

This article describes the complex problems associated with opioid dependence during pregnancy. Medical, obstetric, and psychosocial problems are presented. Methadone maintenance for the treatment of opioid dependence is described in this article. Specific issues of appropriate methadone dose during pregnancy, medical withdrawal, and the relationship of methadone dose and the severity of neonatal abstinence also are discussed.

Perinatal addiction: Outcome and management

The care of the pregnant drug-dependent woman and her newborn infant has become a major and controversial health problem requiring specific approaches to this high-risk mother and neonate. A comprehensive approach to the care of 278 pregnant drug-dependent women and their infants at the Philadelphia General Hospital has significantly reduced maternal and infant morbidity heretofore associated with pregnancies complicated by opiate addiction. Most significantly, the incidence of low birth weight has been reduced to below 20 per cent, and a decrease in severe withdrawal in infants born to mothers in the comprehensive care program has occurred. We propose that application of this approach to women whose pregnancies are complicated by drug dependency is a significant factor in successful management.

Methadone and buprenorphine for the management of opioid dependence in pregnancy.

This article provides an overview and discussion of the collective maternal, fetal and neonatal outcome research on women maintained on methadone or buprenorphine during pregnancy. Its focus is on an assessment of the comparative effectiveness of methadone and buprenorphine pharmacotherapy, with particular attention given to recent findings from the literature. Recommendations for clinical practice are outlined, and directions for future research are presented.Findings from comparative studies of methadone and buprenorphine underscore the efficacy of both medications in preventing relapse to illicit opioid use in the treatment of opioid-dependent pregnant patients, as well as the simplicity of induction onto methadone and patient retention while receiving such therapy. Fetal monitoring suggests that buprenorphine results in less fetal cardiac and movement suppression than does methadone. The clinical implications of these findings need future exploration. For the neonate, evidence from studies using a wide range of designs, including retrospective chart reviews, prospective observational studies, and randomized clinical trials, show consistent results, with prenatal exposure to buprenorphine resulting in less severe neonatal abstinence syndrome relative to methadone.Any medication given to pregnant women should be prescribed only after considering the risk: benefit ratio for the maternal-fetal dyad. Medication choices for each opioid-dependent patient during pregnancy need to be made on a patient-by-patient basis, taking into consideration the patient’s opioid dependence history, previous and current treatment experiences, medical circumstances and treatment preferences. Moreover, for a full remission of opioid addiction to be sustainable, both post-partum and across the lifespan, treatment providers must not rely solely on medication to treat their patients but should also utilize women-specific comprehensive treatment models that address the underlying multifaceted complexities of their patient’s lives.

Prenatal drug exposure and maternal and infant feeding behaviour.

Objective: To evaluate feeding difficulties and maternal behaviour during a feeding session with 1 month old infants prenatally exposed to cocaine and/or opiates. Methods: The study is part of the maternal lifestyle study, which recruited 11 811 subjects at four urban hospitals, then followed 1388 from 1 to 36 months of age. Exposure to cocaine and opiates was determined by maternal interview and meconium assay. At the 1 month clinic visit, biological mothers were videotaped while bottle feeding their infants. This sample included 364 exposed to cocaine, 45 exposed to opiates, 31 exposed to both drugs, and 588 matched comparison infants. Mothers were mostly black, high school educated, and on public assistance. Videotapes were coded without knowledge of exposure status for frequency, duration and quality of infant sucking, arousal, feeding problems, and maternal feeding activity and interaction. Results: No cocaine effects were found on infant feeding measures, but cocaine-using mothers were less flexible (6.29 v 6.50), less engaged (5.77 v 6.22), and had shorter feeding sessions (638 v 683 seconds). Opiate exposed infants showed prolonged sucking bursts (29 v 20 seconds), fewer pauses (1.6 v 2.2 per minute), more feeding problems (0.55 v 0.38), and increased arousal (2.59 v 2.39). Their mothers showed increased activity (30 v 22), independent of their infants’ feeding problems. Conclusions: Previous concerns about feeding behaviour in cocaine exposed infants may reflect the quality of the feeding interaction rather than infant feeding problems related to prenatal exposure. However, opiate exposed infants and their mothers both contributed to increased arousal and heightened feeding behaviour.

Prevention and Treatment Issues for Pregnant Cocaine-Dependent Women and Their Infants

ABSTRACT: The increase in cocaine use among pregnant women has created significant challenges for treatment providers. Drug‐dependent women tend to neglect general health and prenatal care. Perinatal management is often difficult due to medical, obstetrical, and psychiatric complications. Research has demonstrated that comprehensive care, including high risk obstetrical care, psychosocial services, and addiction treatment can reduce complications associated with perinatal substance abuse. Research investigating the effectiveness of residential and outpatient treatment for pregnant cocaine‐dependent women also suggests that many biopsychosocial characteristics and issues influence treatment outcomes. Homelessness and psychiatric illness require a more intensive level of care, and abstinence is difficult to maintain for many women in outpatient treatment as they continue to live in drug‐using environments. To optimize the benefit of comprehensive services, services should be provided within a multilevel model of substance abuse treatment including long‐ and short‐term residential, intensive outpatient, and outpatient settings.

Central and autonomic system signs with in utero drug exposure

Aims: To determine risk for central nervous system/autonomic nervous system (CNS/ANS) signs following in utero cocaine and opiate exposure. Methods: A multisite study was designed to determine outcomes of in utero cocaine and opiate exposure. A total of 11 811 maternal/infant dyads were enrolled. Drug exposed (EXP) infants were identified by maternal self report of cocaine or opiate use or by meconium testing. Of 1185 EXP, meconium analysis confirmed exposure in 717 to cocaine (CO) only, 100 to opiates (OP), and 92 to opiates plus cocaine (OP+CO); 276 had insufficient or no meconium to confirm maternal self report. Negative exposure history was confirmed in 7442 by meconium analysis and unconfirmed in 3184. Examiners masked to exposure status, assessed each enrolled infant. Using generalised estimating equations, adjusted odds ratios (OR) and 95% confidence intervals (CI) were estimated for manifesting a constellation of CNS/ANS outcomes and for each sign associated with cocaine and opiate exposure. Results: Prevalence of CNS/ANS signs was low in CO, and highest in OP+CO. Signs were significantly related to one another. After controlling for confounders, CO was associated with increased risk of manifesting a constellation of CNS/ANS outcomes, OR (95% CI): 1.7 (1.2 to 2.2), independent of OP effect, OR (95% CI): 2.8 (2.1 to 3.7). OP+CO had additive effects, OR (95% CI): 4.8 (2.9 to 7.9). Smoking also increased the risk for the constellation of CNS/ANS signs, OR (95% CI) of 1.3 (1.04 to 1.55) and 1.4 (1.2 to 1.6), respectively, for use of less than half a pack per day and half a pack per day or more. Conclusion: Cocaine or opiate exposure increases the risk for manifesting a constellation of CNS/ANS outcomes.

FOLLOW-UP STUDIES OF INFANTS BORN TO METHADONE-DEPENDENT MOTHERS

Twenty-five infants born to methadone-dependent mothers were studied between 6 and 41 months of age for growth, developmental, behavioral and neurological status. Fifty infants of non-drug-dependent mothers of similar socio-economic backgrounds served as controls. Weight was<3rd percentile in 8% of methadone infants and 2.6% of controls(p=0.10)while 26% of methadone infants were < 3rd percentile in height in contrast to none in the control group(p<0.001). Head circumferences were all with ± 2 S D. Gesells developmental schedule showed a mean D.Q. in the study group of 100 (S D ± 8.8)and in the control group 102(S D ± 10.5). There was no significant difference in gross and fine motor, adaptive, personal-social and language behavior between the two groups. Behavior profiles were scored by assigning grades 1 (decreased) to 5 (increased behavior). In the methadone group there was a marked shift toward high scores; the control group profiles were normal. This behavior pattern decreased in intensity and frequency as the children reached 2 years of age. Neurologic examinations were all normal. In conclusion, children born to methadone-dependent mothers as compared to controls show: decreased linear growth under 3½ years of age, behavior characterized by increased activity and intensity of response in the first 18 months of life, and no differences with regard to developmental and neurological status.

49 DEVELOPMENT OF CHILDREN BORN TO WOMEN WHO RECEIVED METHADONE DURING PREGNANCY

Although evidence suggests that infants of methadone dependent women (IMDW) are within normal range in their mental and motor development, this is predictive neither of later intellectual functioning nor the presence of learning disorders. In order to investigate the possible existence of long-term dysfunction, 25 IMDW who underwent abstinence and 25 control Ss are being evaluated at 4 yrs. of age. To date, 10 male and 11 female Ss have been studied. The addicted group, N=9, x age 4.3, were born to methadone maintained women participating in the Family Center Program. The non-addicted group, N=12, x age 4.3, were randomly selected from a stratified population of comparable socioeconomic, race and medical backgrounds. Ss were assessed with: Test of Language Development (TOLD), Imitation of Gestures (IM), Motor Free Visual Perception Test (MVPT), Wechsler Preschool and Primary Scale of Intelligence (WPPSI) and a neurological exam. Group means and standard deviations were:A t-test revealed no significant differences between groups on the WPPSI (t=1.04, p<.05). All neurological exams were normal. This preliminary data suggests that there are no apparent longterm effects on children from prenatal methadone use.

COCAINE AND PREGNANCY: MATERNAL AND INFANT OUTCOME

The number of infants born to women who abuse cocaine is rapidly increasing. Subjects of this study, conducted within a drug treatment program providing pre and postnatal services to drug dependent women(DDW), included 237 pregnant women: 91 cocaine using DDW, 83 non-cocaine using DDW, and 63 non-DDW. The groups were similar for maternal age, socioeconomic status, nicotine use and parity, but differed in race. Abruptio placentae occurred in 8% of the cocaine DDW, 4% of the non-cocaine DDW and in 2% of the non-DDW. Spontaneous abortions, emergency C-sections and meconium staining occurred more often in the cocaine DDW than in either of the other 2 groups. Birth weight and length, head circumference, gestational age, and 1 min. Apgar scores were significantly lower in the infants of cocaine DDW. No differences existed in the occurrence of congenital anomalities and intracranial hemorrhage. There were more premature deliveries in the cocaine (21%) than in the non-cocaine (11%) and comparison (4%) groups. Mean neonatal abstinence scores, which incorporated 21 physiological and behavioral parameters to quantify symptoms, were lower for the cocaine exposed infants. Differences were significant with respect to cry, disturbed tremors, increased muscle tone, excoriations, fever, mottling, and loose stools. The results of this study suggest that: 1)cocaine use in pregnancy adversely effects maternal and infant outcome, 2)exposure to cocaine in-utero does not appear to increase the incidence of neonatal abstinence symptomatology.

Opioid dependence and pregnancy: minimizing stress on the fetal brain.

&NA; Increase in the number of opioid‐dependent pregnant women delivering babies at risk for neonatal abstinence syndrome prompted a US Government Accountability Office report documenting deficits in research and provider knowledge about care of the maternal/fetal unit and the neonate. There are 3 general sources of dependence: untreated opioid use disorder, pain management, and medication‐assisted treatment with methadone or buprenorphine. A survey of methadone patients’ experiences when telling a physician of their pregnancy and opioid dependence demonstrated physician confusion about proper care, frequent negative interactions with the mother, and failures to provide appropriate referral. Patients in pain management were discharged without referral when the physician was told of the pregnancy. Methadone and buprenorphine were frequently seen negatively because they “caused” neonatal abstinence syndrome. Most mothers surveyed had to find opioid treatment on their own. How dependence is managed medically is a critical determinant of the level of stress on both mother and fetus, and therefore another determinant of neonatal health. The effects of both opioid withdrawal stress and maternal emotional stress on neonatal and developmental outcomes are reviewed. Currently, there have been efforts to criminalize maternal opioid dependence and to encourage or coerce pregnant women to undergo withdrawal. This practice poses both acute risks of fetal hypoxia and long‐term risks of adverse epigenetic programming related to catecholamine and corticosteroid surges during withdrawal. Contemporary studies of the effects of withdrawal stress on the developing fetal brain are urgently needed to elucidate and quantify the risks of such practices. At birth, inconsistencies in the hospital management of neonates at risk for neonatal abstinence syndrome have been observed. Neglect of the critical role of maternal comforting in neonatal abstinence syndrome management is an iatrogenic and preventable cause of poor outcomes and long hospitalizations. Rooming‐in allows for continuous care of the baby and maternal/neonatal attachment, often unwittingly disrupted by the neonatal intensive care unit environment. Recommendations are made for further research into physician/patient interactions and into optimal dosing of methadone and buprenorphine to minimize maternal/fetal withdrawal.