Drivers of decision-making regarding infant sleep practices among mothers with opioid use disorder.

OBJECTIVE: To understand the perspectives and perceived facilitators of and barriers to following safe infant sleeping practices among mothers with opioid use disorder (OUD). STUDY DESIGN: Using the Theory of Planned Behavior (TPB) framework, we conducted qualitative interviews with mothers with OUD regarding infant sleep practices. We created codes and generated themes, concluding data collection upon achieving thematic saturation. RESULTS: Twenty-three mothers with infants 1-7 months of age were interviewed from 08/2020 to 10/2021. Mothers chose sleeping practices they perceived made their infants safer, more comfortable, and minimized infant withdrawal symptoms. Mothers in residential treatment facilities were influenced by facility infant sleep rules. Hospital sleep modeling and varied advice by providers, friends and family influenced maternal decisions. CONCLUSIONS: Mothers reported factors unique to their experience with OUD that influenced their decisions about infant sleep that should be considered when developing tailored interventions to promote safe infant sleep in this population.

Accelerated Fentanyl Metabolism During Pregnancy and Impact on Prenatal Drug Testing.

OBJECTIVE: To evaluate the metabolic pattern of illicit fentanyl in a sample of pregnant patients with opioid use disorder. Fentanyl pharmacokinetics during pregnancy are currently understudied yet the interpretation of a fentanyl immunoassay during pregnancy has significant implications on maternal legal custody and child welfare. Through this medical-legal lens, we demonstrate the utility of an emerging metric, the metabolic ratio, for accurate analysis of fentanyl pharmacokinetics during pregnancy. METHODS: We conducted a retrospective cohort analysis using the electronic medical records of 420 patients receiving integrated prenatal and opioid use disorder care at a large urban safety net hospital. Data related to maternal health and substance use were collected for each subject. The metabolic ratio was calculated for each subject to measure their rate of metabolism. The sample's (n = 112) metabolic ratios were compared with a large non-pregnant sample (n = 4366). RESULTS: The metabolic ratios of our pregnant sample were significantly (p = .0001) higher than the metabolic ratios of our non-pregnant sample, indicating that the rate of conversion to the major metabolite was faster in pregnant people. The effect size for this difference between the pregnant and non-pregnant sample was large (d = 0.86). CONCLUSIONS FOR PRACTICE: Our findings characterize the unique metabolic pattern of fentanyl in pregnant people who use opioids, providing guidance for institutional policies around fentanyl drug testing. Additionally, our study warns of misinterpretation of toxicology results and stresses the importance of physician advocacy on behalf of pregnant women who use illicit opioids.

What is already known on the subject? Widespread use of illicit fentanyl is a dangerous public health threat yet little is known about fentanyl metabolism.What this study adds? This study highlights the difference between fentanyl metabolism in pregnant and non-pregnant people. Providers caring for pregnant patients must be cautious when interpreting fentanyl test results since a positive test may not always indicate recent use. These data can assist in accurate interpretation of urine fentanyl tests during pregnancy.

Understanding cigarette smoking among mothers with opioid use disorder.

BACKGROUND: Cigarette smoking is highly prevalent among mothers with opioid use disorder (OUD). Organizations such as the American College of Obstetrics and Gynecology recommend cessation of cigarettes during the pre- and postnatal periods. Factors that inform decisions to continue or stop smoking cigarettes among pregnant and postpartum mothers with OUD are unclear. AIMS: This study aimed to understand (1) the lived experience of mothers with OUD regarding cigarette smoking and (2) barriers and facilitators to reduction of cigarette smoking during the pre- and postnatal periods. METHODS: Guided by the Theory of Planned Behavior (TPB) framework, we completed semi-structured, in-depth interviews with mothers with OUD with infants 2-7 months of age. We used an iterative approach to analysis by conducting interviews and developing and revising codes and themes until we reached thematic saturation. RESULTS: Fifteen of 23 mothers reported smoking cigarettes prenatally and postnatally, 6 of 23 smoked cigarettes during the prenatal period only, and 2 mothers were non-smokers. We found that mothers: 1) believed that smoke exposure had negative health consequences and may exacerbate withdrawal symptoms for their infants; 2) implemented risk mitigation practices, which were dictated both by themselves and by outside rules, to reduce the harmful effects of smoke around infants; 3) were motivated to quit or cut-down on smoking because of the desire to optimize the health and well-being of their infants; 4) continued to smoke because they felt that the stress related to caregiving and their own recovery were a higher priority than quitting smoking; and 5) were influenced by exposure to smokers with whom they lived, as well as by the varied advice of medical providers, family, and friends. CONCLUSION: While mothers with OUD acknowledged the negative health impact of cigarette smoke exposure to their infants, many experienced stressors related to recovery and caregiving unique to those with OUD that impacted their cigarette smoking behaviors.

Breastfeeding Decision-Making Among Mothers with Opioid Use Disorder: A Qualitative Study.

Background: Factors that contribute to low initiation and continuation of breastfeeding among mothers with opioid use disorder (OUD) are poorly understood. Objective: To understand barriers and facilitators to breastfeeding initiation and continuation beyond the birth hospitalization for mothers with OUD. Materials and Methods: We conducted 23 in-depth, semistructured interviews with mothers with OUD who cared for their infants at home 1-7 months after birth. Our interview guide was informed by the Theory of Planned Behavior (TPB) framework, which has been used to understand decision-making regarding breastfeeding. An iterative approach was used to develop codes and themes. Results: Among 23 participants, 16 initiated breastfeeding, 10 continued after hospital discharge, and 4 continued beyond 8 weeks. We identified factors influencing breastfeeding decisions in the four TPB domains. Regarding attitudes, feeding intentions were based on beliefs of the healthiness of breastfeeding particularly pertaining to infant withdrawal or exposure to mothers' medications. Regarding social norms, breastfeeding was widely recommended, but mothers had varying levels of trust in medical professional advice. Regarding perceived control, infant withdrawal and maternal pain caused breastfeeding to be difficult, with decisions to continue modulated by level of outside support. Regarding self-efficacy, mothers weighed their own recovery and well-being against the constant demands of breastfeeding, impacting decisions to continue. Conclusion: Mothers with OUD face unique barriers to breastfeeding related to their infants' withdrawal as well as their own health, recovery, and social context. Overcoming these barriers may serve as future intervention targets for breastfeeding promotion among this high-risk population.

Temporal encoding: Relative and absolute representations of time guide behavior.

Temporal information-processing is critical for adaptive behavior and goal-directed action. It is thus crucial to understand how the temporal distance between behaviorally relevant events is encoded to guide behavior. However, research on temporal representations has yielded mixed findings as to whether organisms utilize relative versus absolute judgments of time intervals. To address this fundamental question about the timing mechanism, we tested mice in a duration discrimination procedure in which they learned to correctly categorize tones of different durations as short or long. After being trained on a pair of target intervals, the mice were transferred to conditions in which cue durations and corresponding response locations were systematically manipulated so that either the relative or absolute mapping remained constant. The findings indicate that transfer occurred most readily when relative relationships of durations and response locations were preserved. In contrast, when subjects had to re-map these relative relations, even when positive transfer initially occurred based on absolute mappings, their temporal discrimination performance was impaired, and they required extensive training to re-establish temporal control. These results demonstrate that mice can represent experienced durations both as having a certain magnitude (absolute representation) and as being shorter or longer of the two durations (an ordinal relation to other cue durations), with relational control having a more enduring influence in temporal discriminations. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Predictors of the Rate of Illicit Fentanyl Metabolism in a Cohort of Pregnant Individuals.

INTRODUCTION: Illicit fentanyl use is growing in the United States, including among pregnant persons. Despite the prevalence of illicit fentanyl in the drug supply, the pharmacokinetics of fentanyl remains understudied, especially for pregnant individuals. The variability of fentanyl pharmacokinetics influences detection of fentanyl in urine samples, the results of which can have significant legal consequences. For pregnant and parenting individuals, these legal consequences may include termination of parental rights. METHODS: Through this medical-legal lens, we conducted a retrospective cohort analysis using the electronic medical records of women receiving integrated prenatal care and substance use disorder treatment. A total of 420 medical records were reviewed and 112 individuals who had a positive fentanyl immunoassay and met the selection criteria were included. Metabolic ratios (level of norfentanyl/level of fentanyl) were calculated for each study individual. A linear regression analysis was used to determine if the following physiologic factors were predictors of the rate of fentanyl metabolism: hepatic function, renal function, body mass index, medication dosage, gestational age, and maternal age. RESULTS: Results indicated that advanced maternal age predicted a slower conversion of fentanyl to norfentanyl, whereas increased gestational age predicted a faster conversion. CONCLUSIONS: Variations in fentanyl metabolism in pregnancy highlight the importance of clinician vigilance when interpreting fentanyl rests results, especially for individuals with advancing maternal age. In such cases, clinician caution and advocacy may prevent unwarranted and unjust removal of a child from maternal custody.

False-positive Fentanyl Urine Detection after Initiation of Labetalol Treatment for Hypertension in Pregnancy: A Case Report.

BACKGROUND: Labetalol hydrochloride (LH) is a pharmacologic treatment for hypertensive disease (HD) in pregnancy. However, for pregnant persons with substance use disorders (SUDs), LH may interfere with urine drug testing. CASE SUMMARY: We present 3 pregnant or postpregnant persons with SUDs who experienced presumptive positive urine immunoassays for fentanyl while prescribed LH for perinatal HD. DISCUSSION: Labetalol hydrochloride treatment for HD in pregnancy can result in presumptive positive urine immunoassays for fentanyl. Unrecognized or misinterpreted, this phenomenon can lead to significant consequences for pregnant and postpartum persons with co-occurring substance use and hypertensive disorders. Clinicians caring for pregnant persons with SUDs must be aware of this phenomenon and its sequelae when ordering and interpreting urine immunoassays for fentanyl.

Delayed Norfentanyl Clearance During Pregnancy.

BACKGROUND: We report a case of delayed norfentanyl clearance in a 33-year-old pregnant woman. Norfentanyl is the major metabolite of fentanyl. CASE: A multigravid woman with opioid use disorder presented at 7 weeks of gestation for treatment. Despite opioid abstinence, her urine was positive for norfentanyl on 10 distinct gas chromatography-mass spectrometry urine screens. The results demonstrated a steady decrease of norfentanyl over the course of 70 days after her last fentanyl usage, far exceeding expected rates of fentanyl clearance. CONCLUSION: This case highlights the importance of acknowledging pregnancy, genetic, or medication-induced changes to fentanyl pharmacokinetics when interpreting urine tests, especially given the potential sequelae of a false-positive urine test result.