Time to pay attention: an underrecognized casualty of the opioid epidemic.

Maternal mortality and overdose deaths have both been on the rise in the USA, but the relationship between the two is unclear. Recent reports have pointed toward accidental overdoses and suicides as leading causes of maternal mortality. This short communication collected data on psychiatric-related deaths, suicide and drug overdose, from each state's Maternal Mortality Review Committee to better conceptualize the rate at which these deaths are occurring. Data was collected from each state's most recent online MMRC legislative report and met inclusion criteria if the reports included the number of deaths due to suicide and accidental overdoses during each review period, as well if the report encompassed data from 2017. Fourteen reports met inclusion criteria, cumulatively reviewing 1929 maternal deaths. Of these deaths, 603 (31.3%) were due to accidental overdose, while 111 (5.7%) were due to suicide. These findings highlight the need for increased psychiatric care in the pregnant and postpartum period, specifically for substance use disorders. Increasing screening for depression and substance use, decriminalizing substance use during pregnancy, and extending Medicaid coverage to 12 months postpartum on a national level are all interventions that could significantly reduce maternal deaths.

Implementation and Preliminary Effectiveness of a Multidisciplinary Telemedicine Pilot Initiative for Patients with Chronic Non-Cancer Pain in Rural and Underserved Areas at a Major Academic Medical Center.

Background: Arkansas lacks adequate access to high-quality pain care, as evidenced, in part, by it having the second highest opioid prescribing rate in the United States. To improve access to high-quality treatment of chronic pain, we developed the Arkansas Improving Multidisciplinary Pain Care and Treatment (AR-IMPACT) Telemedicine Clinic, a multidisciplinary and interprofessional team of specialists who provide evidence-based pain management for patients with chronic pain. Methods: We conducted a single-arm pilot trial of the AR-IMPACT Telemedicine Clinic with rural, university-affiliated primary care clinics. We assessed the AR-IMPACT Telemedicine Clinic using an implementation framework and preliminary effectiveness measures. Specifically, we assessed 5 of the 8 implementation outcomes of the framework (ie, penetration, adoption, acceptability, appropriateness, and feasibility) using a mixed methods approach. To evaluate implementation outcomes, we used surveys, interviews, and administrative data. We used electronic health record data to measure preliminary effectiveness (ie, changes in average morphine milligram equivalents per day and pain and depression scores). Results: The AR-IMPACT team saw 23 patients that were referred by 13 primary care physicians from three rural, university-affiliated primary care clinics over one year. Of the 19 patients willing to participate in the pilot study, 12 identified as women, 31.6% identified as Black, and over 50% had less than a bachelor's level education. Patients rated the clinic positively with high overall satisfaction. Referring physicians indicated high levels of appropriateness, acceptability, and feasibility of the program. AR-IMPACT team members identified several barriers and facilitators to the feasibility of implementing the program. No changes in preliminary effectiveness measures were statistically significant. Conclusion: Overall, the AR-IMPACT Telemedicine Clinic obtained moderate penetration and adoption, was highly acceptable to patients, was highly acceptable and appropriate to providers, and was moderately feasible to providers and AR-IMPACT team members.

Women's Mental Health Services and Pregnancy: A Review.

IMPORTANCE: The importance of women's mental health services is becoming more evident as we learn more about the impact of mental health on maternal and perinatal outcomes. OBJECTIVE: The purpose of this review is to identify the importance of mental health issues arising during pregnancy including prevention, timely diagnosis and treatment, and referral to specialized services. EVIDENCE ACQUISITION: A literature search was undertaken using the search engines PubMed, CINAHL, and PsycINFO. The search terms were as follows: "mental health services" or "behavioral health" or "mental health counseling" or "psychological" and "delivery of health care" and "pregnancy" or "pregnant." The years searched were January 2000 to November 2020. The search was limited to English language. RESULTS: Of the 255 abstracts identified and reviewed, 35 full-text articles were the basis of this review. Literature summarizing the availability and models of care for mental health services for pregnant women is limited. After reviewing the literature, the themes of depression and anxiety in the antepartum and postpartum periods that emerged as mental health issues, especially during adolescent pregnancies, the coronavirus pandemic, intimate partner violence, and pregnancy loss, are of primary importance to obstetrical providers. All of these issues can have a significant impact on maternal and neonatal outcomes and should be addressed during routine practice. CONCLUSIONS: Maternal mental health is garnering deserved attention and has enormous implications on maternal and infant outcomes. Obstetrical providers should be comfortable with screening, identification, and basic treatment algorithms including when to refer to specialized services. RELEVANCE: Mental health issues during pregnancy and the postpartum period can be profound with severe maternal and perinatal consequences.

A program evaluation of Arkansas Improving Multidisciplinary Pain Care and Treatment (AR-IMPACT).

OBJECTIVE: Arkansas Improving Multidisciplinary Pain Care and Treatment (AR-IMPACT) is an interprofessional team that delivers televideo case conferences to help providers optimize treatment of pain using nonopioid, evidence-based therapies. This article assesses AR-IMPACT using the RE-AIM (reach, efficacy, adoption, implementation, maintenance) framework. DESIGN: A cross-sectional study. SETTING: Large, academic medical center. PARTICIPANTS: Healthcare providers. INTERVENTIONS: Televideo case conferences. MAIN OUTCOME MEASURES: Reach was evaluated by the number of participants, professions represented, and counties/states in which providers resided. Efficacy was assessed via a participant evaluation survey. Adoption was evaluated by calculating the number of repeat participants and soliciting information on barriers to adoption of conference recommendations in clinical practice using the participant evaluation survey. Implementation was evaluated by calculating the time and cost burden of the program. RESULTS: Reach was widespread; continuing education (CE) credits have been claimed by 395 providers in 54 of the 75 counties in Arkansas and 18 states outside Arkansas. For efficacy, the majority of providers noted increases in their knowledge due to AR-IMPACT (89.6 percent). Like reach, adoption was also extensive; approximately 42 percent of AR-IMPACT participants attended more than one conference, and close to 56 percent of participants noted no barriers to adopting the changes discussed in the conferences. With implementation, the time requirements for developing a case conference ranged from 2 to 4 hours, and the cost per CE credit was $137, which is on par with other programs. CONCLUSIONS: AR-IMPACT was successful, particularly in reach and efficacy. Entities that implement programs similar to AR-IMPACT will likely experience extensive uptake by providers.

Clearance of buprenorphine during pregnancy and neonatal outcomes.

Buprenorphine is emerging as the preferred pharmacologic treatment for opioid use disorder during pregnancy. We examined the relative plasma clearance of buprenorphine (BUP) across pregnancy. Pregnant women with opioid use disorder participating in a prospective, observational study from 2013 to 2016 on stress in pregnancy who were receiving BUP for opioid use disorder were included. Women with an active eating disorder or suicidal ideation were excluded. Research visits occurred at 4-6-week intervals across pregnancy and the early postpartum period and included medication exposure history and blood samples. All assays for BUP serum concentrations at steady state were completed. Relative weight-adjusted clearance (Cl) was calculated using Cl = (daily dose [mg]/ body weight [kg])/serum concentration [ng/ml]. We collected 112 maternal blood samples from 29 women throughout pregnancy and the postpartum period. Serum concentrations for BUP ranged from < 0.2 to 15.8 ng/ml. Eleven women, with greater than three collected samples, increased their daily dose of BUP during pregnancy; however, there were no significant differences in relative clearance of BUP across this same period. This data suggests that women with opioid use disorder receiving BUP did not demonstrate a significant increase in BUP clearance across pregnancy despite increase in dosages during pregnancy. When selecting an appropriate BUP dosage for management of perinatal opioid use disorder, gestational stage appears not to be an important covariate and should be based on an individualized approach.

Continuous Fetal Monitoring During Electroconvulsive Therapy: A Prospective Observation Study.

OBJECTIVE: The use of electroconvulsive therapy in pregnancy has been limited by concerns about its effects on fetal well-being, despite limited evidence that suggests it is safe and effective. No studies have utilized continuous fetal heart rate monitoring during electroconvulsive therapy sessions. We aimed to describe the fetal heart rate patterns of patients undergoing electroconvulsive therapy. DESIGN: This study is a prospective case series of pregnant patients undergoing electroconvulsive therapy with continuous fetal heart rate monitoring. SETTING: University-based hospital. POPULATION: Pregnant patients with a psychiatric indication for electroconvulsive therapy. METHODS: Patients underwent fetal heart rate monitoring immediately prior, during and immediately after ECT therapy. MAIN OUTCOME MEASURES: Characterization of the fetal heart rate tracing. RESULTS: Five subjects underwent 44 electroconvulsive therapy sessions. Continuous fetal monitoring was performed on 34 of the sessions. Transient fetal heart rate decelerations occurred in 4 sessions, all self-resolved and none required intervention. CONCLUSION: This case series is the first to report the results of continuous FHR monitoring during electroconvulsive therapy. The most common finding was a transient, self-resolving bradycardia that was not associated with adverse perinatal outcomes. This supports the opinion that electroconvulsive therapy is a safe treatment option in pregnancy in women with severe mental disease.

Buprenorphine Medication for Opioid Use Disorder: A Study of Factors Associated With Postpartum Treatment Retention.

BACKGROUND AND OBJECTIVES: The factors associated with medication for opioid use disorder (MOUD) treatment retention among pregnant women with opioid use disorder (OUD) are largely unknown. This study sought to characterize factors associated with postpartum treatment retention. METHODS: A retrospective chart review from 2014 to 2017 was conducted among women with OUD in pregnancy treated with buprenorphine. Women were assigned to the treatment retention group if they attended an appointment within 10 to 14 weeks postpartum. Others were assigned to the dropout group. The groups were compared using bivariate analysis for sociodemographic variables, obstetrical and neonatal outcomes, clinical and subjective opioid withdrawal symptoms, buprenorphine dosage, urine drug toxicology (UDT) results, and other factors. RESULTS: A total of 64 pregnancies received treatment until delivery, and 47 (73.1%) were retained in treatment by 12 weeks postpartum. The treatment dropout group had lower buprenorphine doses at delivery, a higher percentage of benzodiazepine positive UDT, and number of UDT positive for benzodiazepine in the third trimester. Breastfeeding rates were higher in the treatment retention group. DISCUSSION AND CONCLUSIONS: Future research of variables related to postpartum treatment retention is needed to provide guidelines regarding MOUD during the perinatal period and to optimize maternal and fetal well-being. SCIENTIFIC SIGNIFICANCE: This study supports previous recommendations that aggressive treatment of withdrawal symptoms in pregnant women with OUD is needed to maximize treatment retention. This is the first study to find that breastfeeding was associated with postpartum treatment retention; while, increased use of benzodiazepines during pregnancy was associated with postpartum treatment dropout. (Am J Addict 2021;30:43-48).

Drug screening during pregnancy: Urine dip cups measure up.

BACKGROUND: Substance use during pregnancy is a major medical and public health concern. Determination of the most appropriate screening protocol remains a clinical conundrum. Interviews and/or laboratory drug screens may be costly, inaccurate, and are frequently inadequate to identify patterns of substance use for a given population or geographic area. We compared commercially available urine "dip cup" toxicology screens obtained in the clinic to university hospital drug toxicology results. METHODS: 267 observed urine samples were collected from pregnant women with known substance use disorders enrolled in a specialized treatment program that included access to buprenorphine medication-assisted treatment. Each urine sample was tested by commercial dip cup with temperature confirmation and then sent to the university hospital laboratory for analyses. The number of substances detected and cost for each screening method were compared. RESULTS: Uniformly, the dip cup had comparable detection of amphetamines, barbiturates, cocaine, methadone, opiates, and tetrahydrocannabinol to the university hospital laboratory with the exception of benzodiazepines. In addition, the dip cup detected use of buprenorphine (a commonly misused opiate receptor ligand not included in the hospital screen) and was significantly less expensive. CONCLUSIONS: Commercially available urine dip cups are cost-effective, equally comparable to hospital based screening, and provide 'real time' results germane to clinical care and treatment planning.

Chronic Pain Prevalence and Exposures during Pregnancy.

Pregnant women with chronic pain present a unique clinical challenge for both chronic pain and obstetrical providers, and clinical guidelines do not exist. The present study describes the prevalence and management of chronic pain during pregnancy in a perinatal mood disorder clinic. A retrospective chart review of pregnant women who presented to the Women's Mental Health Program at the University of Arkansas for Medical Sciences (UAMS) for an initial evaluation from July 2013 to June 2016 was conducted to obtain demographic and medical information, including pharmacological exposures. Data are described using the mean and standard deviation for continuous data and frequency for categorical data. Pain complaints and medications are presented as counts and percentages. Differences between women with and without chronic pain were assessed by t-tests for continuous variables and chi-square analysis for categorical variables. Of the 156 pregnant women, chronic pain conditions were reported by 44 (28.2%). The most common chronic pain complaints included neck and/or back pain (34.1%) and headaches (31.8%). Of subjects with chronic pain, 95.5% were taking at least one prescription medication (mean = 2.6 ± 2.1, range of 0-10). Acetaminophen (43.2%) and opioids (43.2%) were the most common. The complexity of managing maternal benefits of treatment with the risks of fetal exposures presents a uniquely challenging clinical scenario for healthcare providers.

Claims for contraceptive services among young women filling chronic opioid prescriptions.

OBJECTIVE: To describe claims for contraceptive services among reproductive-aged women filling chronic opioid prescriptions. STUDY DESIGN: Using a large US commercial claims database, IMS Lifelink+, we identified women aged 15-44 years who filled chronic opioid prescriptions (defined as a 90-day supply of opioids without a 30-day gap over a 180-day time period) and had continuous pharmacy and medical enrollment for at least 90 days prior to and 180 days following their index opioid prescription. After excluding women with any claims for pregnancy-related services, we describe claims for contraceptive prescriptions. RESULTS: We identified 16,074 women with claims for chronic opioids who had filled an average of 135±28-day supply of opioids over a 180-day period. Of these, 23.4% (n=3759) had a claim for prescription contraception in the 90 days prior or 180 days following their index opioid claim. Of those who had claims for prescription contraception, 70% (n=2642) received oral contraceptives; only 2% had claims related to a long-acting reversible contraceptive (i.e., a contraceptive implant or intrauterine device). CONCLUSIONS: Commercially insured women filling chronic opioid prescriptions may have unmet needs for prescription contraception. IMPLICATIONS: Efforts are needed to ensure that the reproductive health needs of women filling chronic opioid prescriptions are met.

Buprenorphine medication-assisted treatment during pregnancy: An exploratory factor analysis associated with adherence.

BACKGROUND: The treatment of pregnant women with opioid use disorder is challenging due to the myriad of physical, mental, and social complications. Factors influencing adherence to buprenorphine during pregnancy have not been identified. MATERIALS AND METHODS: Pregnant women with opioid use disorder followed in a tertiary clinic were included in a retrospective chart review from buprenorphine induction through delivery. All women who had been evaluated and treated with buprenorphine from January 1, 2014, to September 31, 2016, were included. Adherence was defined as follows: 1) adherent: attended follow up visits, negative urine toxicology screens, and phase advancement; 2) moderately adherent: attended follow up visits until delivery, had not completed six negative urine toxicology screens, or had positive urine toxicology screens (i.e., no phase advancement); 3) non-adherent: missed follow up visits and did not stay in treatment until delivery. Sociodemographic characteristics, family psychiatric history, current and lifetime psychiatric and childhood trauma along with treatment factors were compared by category of adherence. RESULTS: 64 women met criteria for inclusion in this study with 41 (64%) adherent; eight (13%) moderately adherent; and 15 (23%) non-adherent. In the non-adherent group compared to the adherent group, the clinician-rated opioid withdrawal scale score was significantly higher, and the daily buprenorphine dose at last visit was significantly lower. CONCLUSIONS: Women who were non-adherent to buprenorphine during pregnancy had higher severity of opioid withdrawal symptoms and lower doses of buprenorphine. These findings should be further explored with the goal of optimizing care without increasing risk for neonates.

Fetal assessment in buprenorphine-maintained women using fetal magnetoencephalography: a pilot study.

BACKGROUND AND AIMS: In-utero exposure to opioids including buprenorphine (BUP) has been shown to affect fetal activity, specifically heart-rate variability (FHRV) and fetal movement (FM). Our objective was to extract simultaneous recordings of fetal cardiac and brain-related activity in BUP-maintained and non-opioid exposed pregnant women using a novel non-invasive biomagnetic technique. DESIGN: A pilot study was conducted, recording and analyzing biomagnetic data from fetuses of BUP-maintained and non-opioid exposed pregnant women. Signals were acquired with the non-invasive 151-channel SARA (SQUID-Array for Reproductive Assessment) system. Advanced signal-processing techniques were applied to extract fetal heart and brain activity. SETTING: University of Arkansas for Medical Sciences (UAMS, Little Rock, Arkansas, USA). PARTICIPANTS: Eight BUP-maintained pregnant women from UAMS Women's Mental Health Program between gestational ages (GA) of 29-37 weeks who were treated with 8-24 mg of BUP daily. Sixteen pregnant women with no known opioid exposure in the same GA range were also included. MEASUREMENTS: Outcome measures from the fetal heart and brain signals included: heart rate (FHR), FM, FHR accelerations, FHR-FM coupling, FHRV, fetal behavioral states (FBS) and power spectral density (PSD) of spontaneous brain activity. These measures were analyzed at three GA intervals. FINDINGS: Fetal heart and brain activity parameters were extracted and quantified successfully from 18 non-opioid and 16 BUP recordings. Overall analysis in both groups show that: FHR and FM ranged from 131 to 141 beats per minute (b.p.m.) and 5 to 11 counts, respectively. In the 35-37 weeks GA, the coupling duration (~9 s) was the shortest, while three of the FHRV parameters were the highest. The PSD of brain activity revealed highest power in 0.5-4 Hz bandwidth. Transitions in FBS from quiet to active sleep were > 50% of sessions. CONCLUSIONS: This pilot study showed that a novel biomagnetic technique allows simultaneous quantification of cardiac and brain activities of a group of buprenorphine-exposed and non-exposed fetuses in the third trimester.

Chronic pain during pregnancy: a review of the literature.

BACKGROUND AND PURPOSE: The majority of the reviews and studies on chronic pain in pregnancy have primarily focused on the pharmacological and non-pharmacological treatment options. The purpose of our review was to identify evidence-based clinical research for the evaluation and management of preexisting chronic pain in pregnancy, chronic pain associated with pregnancy, and chronic pain in relation to mode of delivery. METHODS: A literature search was undertaken using the search engines PubMed, CINAHL, EBSCOhost, and Web of Science. Search terms used included "chronic pain" AND "pregnant OR pregnancy" OR "pregnancy complications" from inception through August 2016. RESULTS: The basis of this review was the 144 articles that met inclusion criteria for this review. Based on our review of the current literature, we recommend 7 guidelines for chronic pain management during and after pregnancy: 1) complete history and physical examination; 2) monitor patients for alcohol, nicotine, and substance use; 3) collaborate with patient to set treatment goals; 4) develop a management plan; 5) for opioids, use lowest effective dose; 6) formulate a pain management plan for labor and delivery; and 7) discuss reproductive health with women with chronic pain. CONCLUSION: The management of chronic pain associated with pregnancy is understudied. Obstetrical providers primarily manage chronic pain during pregnancy. Some general guidelines are provided for those health care providers until more information is available.

A Randomized Pilot Study Comparing Ketamine and Methohexital Anesthesia for Electroconvulsive Therapy in Patients With Depression.

OBJECTIVE: This randomized controlled pilot study examines the differences in response to electroconvulsive therapy (ECT) as defined by an improvement of depressive symptoms between ketamine and methohexital as the primary anesthetic agent. Adverse effects and cognitive tolerability were also examined. METHODS: Subjects undergoing ECT for unipolar or bipolar depression were randomized to receive ketamine or methohexital as the anesthetic agent. Primary outcome measure includes the Hamilton rating scale for depression (17-item). Secondary outcome measures included the mini-mental status examination and Beck depression inventory. All ratings were conducted masked to anesthetic agent. Because of multiple outcome measures obtained over time, mixed models were used to account for the correlations among the measurements within the subjects. Because outcomes were either normally distributed or approximately normally distributed, general linear mixed models were fit with a random intercept specified. RESULTS: A total of 21 subjects were enrolled, and 16 were randomized (methohexital, n = 8; ketamine, n = 8). The 2 treatment groups did not differ statistically in any demographic characteristic. No statistical difference was found between the ketamine and methohexital groups for an improvement in depressive symptoms (P = 0.6); however, subjects in both groups showed significant improvement in depression over time (ketamine, P < 0.0001; methohexital, P < 0.0001). Mini-mental status examination results did not differ between groups, and fatigue was reported more in subjects receiving ketamine (P = 0.03). CONCLUSIONS: The results of this pilot study are inconclusive because they lack power to support an advantage of ketamine anesthesia compared with methohexital in ameliorating depressive symptoms for electroconvulsive therapy.

Pregnancy and Electroconvulsive Therapy: A Multidisciplinary Approach.

OBJECTIVE: To scrutinize a series of pregnant women treated with electroconvulsive therapy (ECT) at a tertiary treatment center and combine these data with a literature review to refine the treatment guidelines for ECT during pregnancy. METHODS: A retrospective chart review of mentally ill pregnant patients treated with ECT since the establishment of a formal women's mental health program. RESULTS: A total of 8 pregnant women treated with ECT were identified from January 2012 to August 2014. Information was extracted from the medical records of a total of 30 ECT treatments across this group. Subjects received an average of 3.75 ECT treatments (range, 1-7). All women were diagnosed as having a mood disorder (either unipolar or bipolar), and 5 of the 8 women had suicidal ideation. The treatment team for ECT was consistent across all treatments. Two women experienced significant complications after the initial treatment: 1) an acute episode of complete heart block; and 2) acute onset of mania after ECT. Obstetrical complications included 2 women with preterm delivery-one secondary to premature rupture of membranes. No other complications or adverse outcomes were recorded. The 5 women with suicidal ideation had symptom resolution, and significant symptom improvement was noted in 6 of the 8 women. CONCLUSIONS: Electroconvulsive therapy is a safe and effective treatment during pregnancy and of particular benefit in the acute treatment of suicidal ideation.