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.

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.

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.

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.

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.

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 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.