Mishka Terplan

Methamphetamine use among pregnant women.

OBJECTIVE: To estimate trends in the prevalence of methamphetamine treatment during pregnancy in the United States. METHODS: Data were obtained from the Treatment Episode Data Set, an administrative data set that captures admissions to federally funded treatment centers in the United States. Demographic and treatment-related measures were examined among women admitted for methamphetamine use and stratified by year of admission to assess trends over time. RESULTS: From 1994 to 2006 there were 245,970 pregnant women admitted. In 1994, methamphetamine accounted for 8% of admitted pregnant women, rising to 24% by 2006. This proportion was higher than methamphetamine admissions among both nonpregnant women (12%) and men (7%). The majority of methamphetamine admissions occurred in the West (73%) among white (64%) unemployed (88%) women. Over the time of analysis, women admitted for methamphetamine treatment became sicker (measured by increasing co-occurring psychiatric disorders) and more marginalized (measured by increasing dependent-living situations and criminal justice involvement). CONCLUSION: Methamphetamine has become the primary substance compelling treatment during pregnancy. Our findings suggest a need for more effective drug and alcohol screening by clinicians who are positioned to identify and address such concerns outside the criminal justice system. LEVEL OF EVIDENCE: III

Human papillomavirus (HPV) vaccine uptake and completion at an urban hospital

BACKGROUND Despite the benefit of the human papillomavirus (HPV) vaccine in preventing cervical cancer, fewer than half of eligible young women in the United States have initiated the three-vaccine series. Among those who initiate HPV vaccination, large proportions do not complete the three-dose regimen. PURPOSE To evaluate racial and health insurance-related disparities in HPV vaccination. METHODS We analyzed outpatient claims data for 8069 patients, ages 9-26 years, who had gynecologic visits at the University of Maryland Medical Center outpatient clinic from August 2006 to January 2010. RESULTS Thirty-five percent of our sample initiated the vaccine series, including 91% of those ages 9-13. Only 11% of the sample and 33% of the 9-13 age group completed the 3 dose series. A higher proportion of blacks than whites (38% vs. 32%; p<0.01) initiated, and 11% and 12%, respectively, of each race completed. Lower age was strongly correlated with uptake. After adjustment for insurance, blacks were less than half as likely as whites to complete the series in all age groups, and had 0.35 the odds (95% CI 0.26-0.46) of adherence. The uninsured had much lower race-adjusted odds than insured groups for initiation, but had similar adherence rates. Publicly insured individuals were more likely than the privately insured to complete all 3 doses. CONCLUSIONS Of the population of gynecologic service seekers seen at our university-based outpatient practice clinics, a significant minority initiate but do not complete the HPV vaccine series. More blacks than whites initiate the series, but similar proportions of the two races complete. Lack of insurance appears to be a major barrier to initiation, despite free vaccination programs.

A missed opportunity for care: two-visit IUD insertion protocols inhibit placement.

BACKGROUND The intrauterine device (IUD) is a safe, long-acting, highly effective method of birth control. Two-visit protocols for IUD insertion may represent a barrier to IUD uptake. STUDY DESIGN This study is a retrospective database review. We identified Medicaid-insured women who requested IUDs in our urban university-based clinic, which employed a two-visit protocol for IUD insertion. The number of women who returned for IUD insertion was determined. To compare women who underwent insertion to those who did not, bivariate and multivariable analyses were used. RESULTS Of the 708 women who requested IUDs at the initial visit, only 385 had an IUD inserted (54.4%). Single women were less likely to return for IUD placement compared to women who had ever been married (52.4% vs. 70.3%; p<.01). Patients who ordered IUDs at gynecologic visits were more likely to return as opposed to those who had them ordered at obstetrics-related visits (60.5% vs. 50.2%; p<.01). Women who lived >10 miles away from the clinic were less likely to return for IUD insertion than women who lived <10 miles away from the clinic (45.3% vs. 56.2%; p=.03). Race, age and type of IUD ordered were not significantly associated with probability of insertion. CONCLUSIONS Almost half of women who ordered IUDs did not return for insertion, suggesting that two-visit protocols hinder a womans ability to have an IUD placed. We must eliminate barriers to IUD insertion.

Have racial disparities in ovarian cancer increased over time? An analysis of SEER data.

OBJECTIVE Race has been postulated to be a prognostic factor in women with ovarian cancer. The reasons for racial disparities are multifactorial. Recent literature suggests that racial disparities in ovarian cancer survival emerged in the 1980s, when modern treatments such as aggressive surgical debulking and platinum-based chemotherapy first gained widespread use. We suspect that as improvements in treatment have evolved, the effects of access to treatment have amplified racial disparities in survival from ovarian cancer. METHODS SEER 9 data were analyzed, including African American and white patients diagnosed with ovarian cancer from 1973 to 2007, with 2008 as the cutoff for follow-up. Using the Kaplan-Meier method, we evaluated racial differences in survival, to determine whether this difference has increased over time. RESULTS There were 44,562 white and 3190 African American women available for analysis. Overall African Americans had 1.10 times the crude hazard (95% CI 1.06-1.15) of all-cause mortality compared to whites, with a widening trend over time (p<0.01). Adjusted for SEER registry, age, tumor stage, marital status and time of diagnosis, the hazard ratio (HR) for all-cause mortality comparing African Americans to whites was 1.31 (95% CI 1.26-1.37). When the receipt of surgery was added to the model, the HR for all-cause mortality remained higher for African American women at 1.27 (95% CI 1.21-1.34). CONCLUSIONS African Americans diagnosed with ovarian cancer have worse survival than whites, and this disparity has increased over time. Measured differences in treatment, such as receipt of surgery, account for part of the disparity.

Recent trends in treatment admissions for prescription opioid abuse during pregnancy.

Prescription opioid abuse is a significant and costly public health problem among pregnant women in the United States. We investigated recent trends in substance abuse treatment admissions for prescription opioids during pregnancy using the Treatment Episodes Data Set. From 1992 to 2012 the overall proportion of pregnant admissions remained stable at 4%; however, admissions of pregnant women reporting prescription opioid abuse increased substantially from 2% to 28% especially in the south. Demographic characteristics of pregnant opioid admissions changed from 1992 to 2012 with younger, unmarried White non-Hispanic women, criminal justice referrals, and those with a psychiatric co-morbidity becoming more common (p<0.01). About a third received medication assisted therapy despite this being the standard of care for opioid abuse in pregnancy. While substance abuse treatment centers have increased treatment volume to address the increase in prescription opioid dependence among pregnant women, targeting certain risk groups and increasing utilization of medication assisted therapy should be emphasized.

Knowledge, Attitudes, and Practice of Electronic Cigarette Use Among Pregnant Women.

Objective:Electronic cigarettes (e-cigarettes) are a relatively recent phenomenon, serving dual roles as an alternative vehicle for nicotine delivery and a smoking-cessation tool. The purpose of this study was to determine pregnant womens knowledge, attitudes, and practice regarding electronic cigarettes. Study Design:A voluntary, anonymous survey was distributed to a convenience sample of pregnant women presenting to a university-based outpatient clinic. After survey completion, participants received information about smoking cessation and e-cigarettes. Data were examined using &khgr;2 and Fisher exact tests and analysis of variance. Stata was used for the analysis. Results:Of the 326 surveys distributed, 316 were completed (97%). Of the 316 participants, 42 (13%) reported having ever used e-cigarettes. Only 2 (0.6%) reported current daily use. Ever users were slightly older (27.3 years vs 25.4 years; P = 0.007) and more likely to be current smokers (43% vs. 14%; P < 0.001) compared with women who had never used electronic cigarettes. Knowledge of the harms of smoking was similar between the 2 groups. Overall, 57% of all respondents believed that e-cigarettes contain nicotine, 61% that e-cigarettes can be addictive, and 43% that e-cigarettes are less harmful to a fetus than traditional cigarettes. Among ever users, the most common reasons given for the use of e-cigarettes were the perception of less harm than traditional cigarettes (74%) and help with smoking cessation (72%). Conclusions:Misconceptions about e-cigarettes are common among pregnant women, potentially motivating use that may pose risks to both maternal and child health. Screening and education regarding e-cigarettes should be included in prenatal care. Future research in this area is necessary, including research examining pregnancy outcomes among women who use e-cigarettes.

Race in ovarian cancer treatment and survival: a systematic review with meta-analysis

ObjectiveThere has long been recognition of racial disparities in cancer treatment and survival. In order to investigate the etiology of racial disparities in ovarian cancer, we undertook a systematic review of the published literature.MethodsFocusing on North America, our search of MEDLINE, PsychInfo, and EMBASE databases recovered 513 abstracts of which 98 underwent full text screening resulting in 24 studies included in the final review. After assessing heterogeneity, results were pooled where possible in a meta-analysis using a random effects model.ResultsEight articles reported treatment outcomes, nine survival, and seven both. Overall African Americans were less likely to receive any form of surgical treatment for ovarian cancer [pooled relative risk (RR) 1.17 (95% confidence interval (CI): 1.10, 1.23)] compared with white women. Although the majority of the included articles reporting survival outcomes did not control for known covariates such as medical co-morbidities or treatment, we were able to pool the unadjusted results from eight articles. Taken together the meta-analysis of 106,704 women did not find a difference in five-year survival between whites and African Americans, RR 1.07 (95% CI: 0.97, 1.18). When the results were stratified by year of cancer diagnosis, studies which captured patients prior to 1985 yielded a five-year RR of survival for whites compared to African Americans of 0.93 (95% CI: 0.89, 0.97) compared with 1.17 (95% CI: 1.05, 1.31) after 1985.ConclusionThese results suggest that racial disparities in ovarian cancer are not due to underlying biological differences rather to the unequal application of existing treatments.

Effect of a brief educational intervention on the attitudes of young women toward the intrauterine device.

STUDY OBJECTIVE The intrauterine device (IUD) is underused by young women, who are at high risk for unintended pregnancy. We aimed to assess the impact of a brief educational intervention on the attitudes of young women toward intrauterine contraception and to assess characteristics associated with a change in attitude. DESIGN, SETTING, AND PARTICIPANTS This is a planned secondary analysis of a survey of 144 women, aged 14-24 years, which assessed attitudes toward the IUD. INTERVENTION The analysis was planned to fully examine the impact of a 3-minute educational intervention about the IUD given during administration of the survey, which included risks and benefits of IUD use, costs, side effects, and a demonstration of the IUD insertion and removal process. MAIN OUTCOME MEASURE Proportions of participants with a positive attitude toward the IUD before and after the intervention were compared using McNemars chi-square test for paired proportions. Factors associated with a change in attitude toward the IUD were evaluated using multivariable analysis. RESULTS Before the educational intervention, 14.7% (21/143) had both heard of the IUD and expressed a positive attitude toward it. After the intervention, this proportion increased to 53.8% (77/143) (P < .01). The increase in proportion with a positive attitude was consistent for all subpopulations. In multivariable analysis, the only significant predictor of a positive change in attitude toward the IUD was a history of voluntary sexual activity (adjusted odds ratio 10.3, 95% confidence interval 2.0-53.1). CONCLUSIONS A brief educational intervention significantly improves the attitude of young sexually active women toward the IUD.

Contraceptive use and method choice among women with opioid and other substance use disorders: A systematic review.

AIM To systematically review the literature on contraceptive use by women with opioid and other substance use disorders in order to estimate overall contraceptive use and to examine method choice given the alarmingly high rate of unintended pregnancy in this population. METHOD Pubmed (1948-2014) and PsycINFO (1806-2014) databases were searched for peer-reviewed journal articles using a systematic search strategy. Only articles published in English and reporting contraceptive use within samples of women with opioid and other substance use disorders were eligible for inclusion. RESULTS Out of 580 abstracts reviewed, 105 articles were given a full-text review, and 24 studies met the inclusion criteria. The majority (51%) of women in these studies reported using opioids, with much smaller percentages reporting alcohol and cocaine use. Across studies, contraceptive prevalence ranged widely, from 6%-77%, with a median of 55%. Results from a small subset of studies (N=6) suggest that women with opioid and other substance use disorders used contraception less often than non-drug-using comparison populations (56% vs. 81%, respectively). Regarding method choice, condoms were the most prevalent method, accounting for a median of 62% of contraceptives used, while use of more effective methods, especially implants and intrauterine devices (IUDs), was far less prevalent 8%. CONCLUSIONS Women with opioid and other substance use disorders have an unmet need for contraception, especially for the most effective methods. Offering contraception services in conjunction with substance use treatment and promoting use of more effective methods could help meet this need and reduce unintended pregnancy in this population.

Naltrexone in the treatment of opioid-dependent pregnant women: the case for a considered and measured approach to research

The present paper considers naltrexone to treat opioid dependence during pregnancy. The public health problem of opioid dependence and its treatment during pregnancy is reviewed first. Next, the naltrexone and opioid dependence treatment literature is summarized, with overviews of the pre-clinical and clinical research on prenatal naltrexone exposure. Finally, considerations and recommendations for future medication research for the treatment of opioid dependence in pregnant women are provided. The efficacy of long-acting injectable naltrexone relative to placebo, its blockade of opioid agonist euphoric effects, its lack of abuse and tolerance development and its modest adverse effect profile make it a potential medication for opioid-dependent pregnant women. However, it is not without seriously concerning potential drawbacks, including the difficulty surrounding medication induction that may lead to vulnerability with regard to relapse, physical dependence re-establishment, increased risk behaviors, treatment dropout and resulting opioid overdose. Before embarking on future research with this medication, the benefits and risks for the mother-embryo/fetus/child dyad should be weighed carefully. Should future research be conducted, a multi-level commitment to proactive ethical research is needed to reach the ultimate goal of improving the lives of women and children affected by opioid dependence.