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.

Perinatal Transmission of Hepatitis C Virus: Defining the Cascade of Care.

OBJECTIVES: The US National Viral Hepatitis Action Plan calls for major efforts to expand hepatitis C virus (HCV) diagnosis and treatment; prenatal care settings are potential venues for expanding HCV testing. We aimed to characterize the HCV diagnostic cascade for women and infants and investigate factors associated with linkage and follow-up. STUDY DESIGN: We used electronic health records for a 10-year cohort of 879 women with opioid use disorder from an obstetric clinic serving women with substance use disorders. RESULTS: Altogether, 744 women (85%) were screened for HCV; 510 (68%) were seropositive, of whom 369 (72%) had nucleic acid testing performed and of these 261 (71%) were viremic. Of 404 infants born to HCV-seropositive women, 273 (68%) were tested at least once for HCV, 180 (45%) completed the American Academy of Pediatrics-recommended perinatal HCV screening, and 5 (2.8%) were diagnosed with HCV infection and linked to care. More recent delivery date (2014-2015) was associated with maternal linkage to care (aOR, 2.5; 95% CI, 1.4-4.7). Maternal coinfection with HIV (aOR, 9.0; 95% CI, 1.1-72.8) and methadone maintenance therapy, compared with buprenorphine (aOR, 1.5; 95% CI, 0.9-2.5), were associated with higher rates of infant HCV testing. CONCLUSIONS: HCV prevalence among pregnant women with opioid use is high and infant HCV screening is imperfect. Programmatic changes to improve both mother and infant follow-up may help to bridge identified gaps in the cascade to cure.

Prenatal buprenorphine versus methadone exposure and neonatal outcomes: systematic review and meta-analysis.

Increasing rates of maternal opioid use during pregnancy and neonatal withdrawal, termed neonatal abstinence syndrome (NAS), are public health concerns. Prenatal buprenorphine maintenance treatment (BMT) versus methadone maintenance treatment (MMT) may improve neonatal outcomes, but associations vary. To summarize evidence, we used a random-effects meta-analysis model and estimated summary measures of BMT versus MMT on several outcomes. Sensitivity analyses evaluated confounding, publication bias, and heterogeneity. Subjects were 515 neonates whose mothers received BMT and 855 neonates whose mothers received MMT and who were born from 1996 to 2012 and who were included in 12 studies. The unadjusted NAS treatment risk was lower (risk ratio=0.90, 95% confidence interval (CI): 0.81, 0.98) and mean length of hospital stay shorter (-7.23 days, 95% CI: -10.64, -3.83) in BMT-exposed versus MMT-exposed neonates. In treated neonates, NAS treatment duration was shorter (-8.46 days, 95% CI: -14.48, -2.44) and morphine dose lower (-3.60 mg, 95% CI: -7.26, 0.07) in those exposed to BMT. BMT-exposed neonates had higher mean gestational age and greater weight, length, and head circumference at birth. Fewer women treated with BMT used illicit opioids near delivery (risk ratio=0.44, 95% CI: 0.28, 0.70). Simulations suggested that confounding by indication could account for some of the observed differences. Prenatal BMT versus MMT may improve neonatal outcomes, but bias may contribute to this protective association. Further evidence is needed to guide treatment choices.

Case Series of Individuals Treated With Naltrexone During Pregnancy for Opioid and/or Alcohol Use Disorder.

OBJECTIVE: There is a lack of knowledge about the relative safety and efficacy of naltrexone for the treatment of pregnant individuals with opioid and/or alcohol use disorder, including the range of outcomes, in both the pregnant individual and the infant, over the course of peripartum period. Our objective was to describe these outcomes in a cohort of pregnant individuals on naltrexone. METHODS: In this prospective case series, 7 pregnant individuals with opioid use disorder (OUD) or alcohol use disorder (AUD) treated with naltrexone were followed from pregnancy through 12 months after delivery. Clinical treatment protocols and outcomes related to safety and efficacy during pregnancy, delivery, and the postpartum period are described. RESULTS: There were 4 pregnant individuals with OUD and 3 with AUD, of which 3 were managed with oral and 4 with extended-release naltrexone. The mean gestational age at study enrollment was 21.7 (SD, 12) weeks. Of the 7 participants, there was no return to nonprescribed opioid use and 2 who experienced a return to alcohol use over the course of the study. All individuals delivered vaginally at a mean of 37 weeks gestation without any peripartum pain difficulties. Five of the individuals (71.4%) remained on naltrexone 12 months after delivery. There were no reported fetal anomalies and one preterm delivery. None of the infants developed neonatal opioid withdrawal syndrome. CONCLUSIONS: For pregnant individuals with OUD or AUD treated with naltrexone, there were low rates of return to nonprescribed use and reassuring pregnant person and infant outcomes to 12 months postpartum.

Neurobehavioral outcomes of infants exposed to buprenorphine-naloxone compared with naltrexone during pregnancy.

BACKGROUND: Naltrexone is a medication used to treat both opioid and alcohol use disorder with limited experience in pregnant individuals, particularly in comparison to more commonly utilized treatments such as buprenorphine-naloxone. The long-term outcomes of infants exposed to naltrexone has not been previously examined. AIMS: To compare the neurobehavioral outcomes of naltrexone versus buprenorphine-naloxone exposed infants. STUDY DESIGN: Multi-centered prospective cohort study. SUBJECTS: Pregnant people on prescribed buprenorphine-naloxone or naltrexone were enrolled during pregnancy and the dyad followed until 12 months after delivery. OUTCOME MEASURES: Infants were evaluated at 4-6 weeks corrected gestational age (CGA) using the NICU Neonatal Neurobehavioral Scale (NNNS) and at the 12-month CGA visit using the Ages and Stages Questionnaire, Third Edition (ASQ-3). RESULTS: There were 7 dyads in the naltrexone group and 34 in the buprenorphine-naloxone group. On the NNNS, infants exposed to naltrexone had higher median scores for arousal and excitability, and lower median scores for attention and regulation at 4-6 weeks CGA compared to the buprenorphine-naloxone group. None of the infants in the naltrexone group were monitored for NOWS and had shorter length of hospital stay compared with the buprenorphine-naloxone group. Although no statistically significant differences were observed, more infants in the buprenorphine-naloxone group were identified as at risk for development delays in the communication, problem solving, and personal social domains of the ASQ-3 at 12 months CGA. Results should be interpreted with caution given this study's small sample size and lack of a prospective comparison cohort. CONCLUSIONS: In this small cohort, there are differences noted in infant neurobehavior by NNNS at 4-6 weeks of age when comparing the buprenorphine-naloxone and naltrexone groups. At 12 months, ASQ-3 scores were similar but with percentage differences in potential development delay risk observed between the two groups. Larger cohort studies are needed to determine the long-term child outcomes after naltrexone exposure in pregnancy.

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.

Academy of Breastfeeding Medicine Clinical Protocol #21: Breastfeeding in the Setting of Substance Use and Substance Use Disorder (Revised 2023).

Background: The Academy of Breastfeeding Medicine (ABM) revised the 2015 version of the substance use disorder (SUD) clinical protocol to review the evidence and provide updated literature-based recommendations related to breastfeeding in the setting of substance use and SUD treatments. Key Information: Decisions around breastfeeding are an important aspect of care during the peripartum period, and there are specific benefits and risks for substance-exposed mother-infant dyads. Recommendations: This protocol provides breastfeeding recommendations in the setting of nonprescribed opioid, stimulant, sedative-hypnotic, alcohol, nicotine, and cannabis use, and SUD treatments. Additionally, we offer guidance on the utility of toxicology testing in breastfeeding recommendations. Individual programs and institutions should establish consistent breastfeeding approaches that mitigate bias, facilitate consistency, and empower mothers with SUD. For specific breastfeeding recommendations, given the complexity of breastfeeding in mothers with SUD, individualized care plans should be created in partnership with the patient and multidisciplinary team with appropriate clinical support and follow-up. In general, breastfeeding is recommended among mothers who stop nonprescribed substance use by the time of delivery, and they should continue to receive ongoing postpartum care, such as lactation support and SUD treatment. Overall, enhancing breastfeeding education regarding substance use in pregnancy and lactation is essential to allow for patient-centered guidance.

National Provider Survey: Use of Naltrexone for Pregnant Individuals with Substance Use Disorders.

OBJECTIVES: A national survey evaluated the availability of naltrexone as a treatment for alcohol use disorder and/or opioid use disorder for pregnant individuals. Provider perceptions of barriers to treatment with naltrexone during pregnancy were also examined. METHODS: Sites were selected from a national registry of naltrexone prescribers (N = 5208). A 10% sampling of sites within 150 miles of each state's capital was selected (n = 2073). Survey of 11 questions included availability of naltrexone for pregnant individuals, standard practices for treating pregnant individuals already on naltrexone, and barriers to treatment. Survey responses were summarized to identify top barriers and national trends in service availability. RESULTS: Of the 236 sites contacted, 78 (33.1%) completed the survey. There was significant geographic variation in number of available sites, with Northeast United States having the most sites. Of the 78 responding sites, only 23 (35.9%) offered naltrexone for pregnant individuals. The most common barriers to prescribing naltrexone included the following: sites without pregnant patients (15.6%), lack of national guidelines in using naltrexone for pregnant patients (14.1%), providers' discomfort with prescribing naltrexone during pregnancy due to safety concerns (9.4%), and providers' discomfort due to inexperience (4.7%). CONCLUSIONS: Accessibility of naltrexone and related care for pregnant individuals with alcohol use disorder and opioid use disorder varies greatly across the United States with numerous barriers and educational gaps identified. Additional research and resources are needed to expand naltrexone treatment access for pregnant individuals.

A comparison of postpartum opioid consumption and opioid discharge prescriptions among opioid-naïve patients and those with opioid use disorder.

BACKGROUND: Management of patients with opioid use disorder during the acute postpartum period remains clinically challenging as obstetricians aim to mitigate postdelivery pain while optimizing recovery support. OBJECTIVE: This study aimed to evaluate postpartum opioid consumption and opioids prescribed at discharge among patients with opioid use disorder treated with methadone, buprenorphine, and no medication for opioid use disorder, as compared with opioid-naïve counterparts. STUDY DESIGN: We conducted a retrospective cohort study of pregnant patients who underwent delivery at >20 weeks' gestation at a tertiary academic hospital between May 2014 and April 2020. The primary outcome of this analysis was the mean daily quantity of oral opioids consumed after delivery while inpatient, in milligrams of morphine equivalents. Secondary outcomes included the following: (1) quantity of oral opioids prescribed at discharge, and (2) prescription for oral opioids in the 6 weeks after hospital discharge. Multiple linear regression was used to compare differences in the primary outcome. RESULTS: A total of 16,140 pregnancies were included. Patients with opioid use disorder (n=553) consumed 14 milligrams of morphine equivalents per day greater quantities of opioids postpartum than opioid-naïve women (n=15,587), (95% confidence interval, 11-17). Patients with opioid use disorder undergoing cesarean delivery consumed 30 milligrams of morphine equivalents per day greater quantities of opioids than opioid-naïve counterparts (95% confidence interval, 26-35). Among patients who underwent vaginal delivery, there was no difference in opioid consumption among patients with and without opioid use disorder. Compared with patients prescribed methadone, patients prescribed buprenorphine, and those prescribed no medication for opioid use disorder consumed similar opioid quantities postpartum following both vaginal and cesarean delivery. Among patients undergoing cesarean delivery, opioid-naïve patients were more likely to receive a discharge prescription for opioids than patients with opioid use disorder (77% vs 68%; P=.002), despite lower pain scores and less inhospital opioid consumption. CONCLUSION: Patients with opioid use disorder, regardless of treatment with methadone, buprenorphine, or no medication for opioid use disorder consumed significantly greater quantities of opioids after cesarean delivery but received fewer opioid prescriptions at discharge.

Supporting the implementation of written exposure therapy for posttraumatic stress disorder in an obstetrics-substance use disorder clinic in the Northeastern United States.

Pregnant people with comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) constitute a highly vulnerable population. PTSD and SUD confer risks to both the pregnant person and the fetus, including a host of physical and mental health consequences. When PTSD and SUD co-occur, potential negative impacts are amplified, and the symptoms of each may exacerbate and maintain the other. Pregnancy often increases engagement in the healthcare system, presenting a unique and critical opportunity to provide PTSD and SUD treatment to birthing people motivated to mitigate risks of losing custody of their children. This paper presents implementation process outcomes of Written Exposure Therapy (WET), a brief, scalable, and sustainable evidence-based PTSD treatment delivered to pregnant persons receiving care in an integrated obstetrical-addiction recovery program at Boston Medical Center. Trial participants (N = 18) were mostly White, non-Hispanic (61.1%), not currently working (77.8%), had a high school or lower level of education (55.5%), had an annual household income less than $35,000 (94.4%), and were living in a substance use residential program (55.6%). We examined intervention feasibility, acceptability, appropriateness, adoption; barriers and facilitators to implementation; and feedback on supporting uptake and sustainability of the intervention using coded qualitative sources (consultation field notes [N = 47] and semi-structured interviews [N = 5]) from providers involved in trial planning and treatment delivery. Results reflected high acceptability, appropriateness, and adoption of WET. Participants described system-, provider-, and patient-level barriers to implementation, offered suggestions to enhance uptake, but did not raise concerns about core components of the intervention. Findings suggest that WET is an appropriate and acceptable PTSD treatment for this difficult-to-reach, complex population, and has the potential to positively impact pregnant persons and their children.

Developing a Women's Health track within addiction medicine fellowship: reflections and inspirations.

BACKGROUND: Women who use drugs face sexism and intersectional stigma that influence their drug use experiences and treatment needs. There is a need to build the capacity of addiction medicine specialists who can deliver gender-responsive services and advance research and policy in women-focused addiction care. We describe the development of a Women's Health track within an addiction medicine fellowship program and reflect on successes, challenges, and future directions. MAIN BODY: The Women's Health track was developed in collaboration between program leaders in Addiction Medicine and Obstetrics/Gynecology. Implementing the track led to the development of women-focused rotations and continuity clinics, as well as enrichment of women's health didactic education for all fellows. The fellowship track spurred interdepartmental mentorship and collaboration on research and advocacy projects. CONCLUSION: Addiction medicine fellowships can replicate this curriculum model to advance women-focused education, research, and policy. Future curricula should focus on structural sexism in drug use and addiction treatment throughout a woman's life course.

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.

Gender Dynamics in Substance Use and Treatment: A Women's Focused Approach.

Gender impacts substance use initiation, substance use disorder development, engagement with treatment, and harms related to drug and alcohol use. Using the biopsychosocial model of addiction, this review provides a broad summary of barriers and facilitators to addiction services among women. It also reviews substance use among pregnant and parenting women and approaches to care. Given the increasing rates of substance use among women, there is a need to implement and scale-up gender-responsive addiction programming and pursue advocacy at the policy level that addresses the root drivers of substance use inequities among women.

Buprenorphine-naloxone Versus Buprenorphine for Treatment of Opioid Use Disorder in Pregnancy.

OBJECTIVES: Data regarding treatment outcomes with the use of buprenorphine-naloxone (BUP-NX) in pregnancy are scarce. The objective of this study is to examine the outcomes in a cohort of pregnancies treated with BUP-NX versus buprenorphine (BUP). METHODS: This single-center, retrospective cohort study examined birthing person-infant dyads treated with BUP-NX versus BUP. The primary birthing person outcome was return to opioid use in pregnancy. The primary neonatal outcome was the need for pharmacologic treatment for neonatal opioid withdrawal syndrome (NOWS). RESULTS: The BUP-NX and the BUP treatment groups included 33 and 73 dyads, respectively. Except for psychiatric medication use, all demographics were similar between groups. In the final regression models, neither the birthing person nor the neonatal outcomes differed. The adjusted odds ratio for return to use during pregnancy for the BUP-NX versus BUP groups was 1.93 (95% confidence interval, 0.78-4.76). The adjusted odds ratio for pharmacologic treatment of NOWS for the BUP-NX versus BUP groups was 0.65 (95% confidence interval, 0.27-1.54). Among a subgroup of persons who transitioned from BUP to BUP-NX mid-pregnancy, there was no proximate return to use or need for dose increase. CONCLUSIONS: Compared with BUP, the use of BUP-NX in pregnancy is not associated with a higher risk of return to opioid use or a higher need for pharmacological treatment for NOWS.

Integrated substance use and prenatal care delivery in the era of COVID-19.

The COVID-19 pandemic has directly impacted integrated substance use and prenatal care delivery in the United States and has driven a rapid transformation from in-person prenatal care to a hybrid telemedicine care model. Additionally, changes in regulations for take home dosing for methadone treatment for opioid use disorder due to COVID-19 have impacted pregnant and postpartum women. We review the literature on prenatal care models and discuss our experience with integrated substance use and prenatal care delivery during COVID-19 at New England's largest safety net hospital and national leader in substance use care. In our patient-centered medical home for pregnant and postpartum patients with substance use disorder, patients' early responses to these changes have been overwhelmingly positive. Should clinicians continue to use these models, thoughtful planning and further research will be necessary to ensure equitable access to the benefits of telemedicine and take home dosing for all pregnant and postpartum patients with substance use disorder.

Enhancing Linkage to Hepatitis C Virus Treatment Following Pregnancy in Women Identified During Perinatal Care.

Amid the current US opioid crisis, hepatitis C virus (HCV) infection rates continue to rise in young adults, including among pregnant women, yet few studies describe linkage to care and treatment in pregnant or postpartum women with HCV infection. We used electronic health record data to estimate HCV treatment rates for postpartum women before (January 2014-September 2016) and during (October 2016-March 2018) implementation of a maternal-infant HCV linkage program in combination with a multidisciplinary clinic to colocate mother and infant care. Using Poisson regression models, we compared HCV treatment initiation rates, adjusting for demographics, substance use, and treatment. From January 2014 through March 2018, 343 women who were HCV seropositive delivered at our institution. Of these, 95% completed HCV nucleic acid testing and 255 women had chronic HCV infection. Mean age was 30 years, 96% were publicly insured, and 94% had documented substance use. HCV treatment initiation increased from 28/164 (17.1%) women with chronic HCV infection in the preintervention period to 16/66 (24.2%) with the linkage-only intervention and 13/25 (52.0%) with the linkage intervention and colocated care. Adjusted analyses demonstrated that women delivering during the intervention period initiated HCV treatment at 2.40 times (95% confidence interval [CI], 1.10-5.25; linkage only) and 3.36 times (95% CI, 1.57-7.17; linkage and colocated care) the rate of women delivering preintervention. Women on buprenorphine had higher HCV treatment initiation rates compared with those on methadone (rate ratio, 2.10; 95% CI, 1.05-4.21). Conclusion: HCV linkage to care and treatment rates improved in the setting of mother-infant linkage and colocated care interventions. Perinatal care may represent a critical venue to identify, link, and treat women for HCV infection to improve their own health and prevent transmission to subsequent pregnancies.

A Retrospective Cohort Study Examining the Utility of Perinatal Urine Toxicology Testing to Guide Breastfeeding Initiation.

OBJECTIVE: National guidelines advise against breastfeeding for women who use nonprescribed substances in the third trimester. This reduces the number of women who are supported in breastfeeding initiation despite limited evidence on the prognostic value of third trimester substance use. We sought to examine the degree to which prenatal nonprescribed substance use is associated with non-prescribed use postpartum. METHODS: Retrospective cohort study of pregnant women with opioid use disorder on methadone or buprenorphine between 2006 and 2015. Nonprescribed use was defined by a positive urine drug testing (UDT). Sensitivity, specificity, positive predictive value, and negative predictive value were calculated comparing 3 prenatal periods with postpartum UDT results. Generalized estimating equations were used to examine the extent to which prenatal nonprescribed use was associated with postpartum use. RESULTS: Included were 545 deliveries by 503 women. Mean age was 28.3 years, 88% were White/non-Hispanic, 93% had public insurance, and 43% received adequate prenatal care. The predictive value of UDT's 90 to 31 days before delivery, 30 to 0 days before delivery, and at delivery showed low sensitivity (44, 26, 27%, respectively) and positive predictive value (36, 36, 56%, respectively), but higher negative predictive value (80, 85, and 78%, respectively), P-values all <0.05. In the final adjusted model, only nonprescribed use at delivery was significantly associated with postpartum nonprescribed use. CONCLUSIONS: Nonprescribed use at delivery was most strongly associated with postpartum use compared with earlier time periods currently prioritized in guidelines. In women with opioid use disorder prenatal UDT results alone are insufficient to guide breastfeeding decisions.

Adaptation of a System of Treatment for Substance Use Disorders During the COVID-19 Pandemic.

The Grayken Center for Addiction at Boston Medical Center includes programs across the care continuum for people with substance use disorders (SUDs), serving both inpatients and outpatients. These programs had to innovate quickly during the COVID-19 outbreak to maintain access to care. Federal and state regulatory flexibility allowed these programs to initiate treatment for people experiencing homelessness and maximize patient safety through physical distancing practices. Programs switched to telehealth with high levels of acceptability and patient retention. Some programs also maintained some face-to-face clinic visits to see patients with complex problems and to provide injectable medications. Text-messaging proved invaluable with adolescent and young adult clients, and a mobile-health outreach program was initiated to reach mother/child dyads affected by SUDs. A 24-hour hotline was implemented to support seamless access to treatment for hundreds released from incarceration early due to the pandemic. Boston Medical Center also launched the COVID Recuperation Unit to allow patients experiencing homelessness to recover from mild to moderate COVID-19 infection in an environment that took a harm-reduction approach to SUDs and provided rapid initiation of medication treatment. Many of these innovations increased access to treatment and retention of patients during the pandemic. Maintaining the revised regulations would allow flexibility to provide telehealth, extended prescriptions, and remote access to buprenorphine initiation to support and engage more patients with SUDs.

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.

28-year-old Woman With Opioid Use Disorder Delivers Healthy Baby While in Custody: Addressing Forced Detox.

BACKGROUND: Opioid agonist treatment (OAT) in pregnancy reduces overdose risk, drug use, increases prenatal care engagement, and improves birth outcomes. Yet many pregnant women lack access to adequate treatment. OAT, while incarcerated, reduces subsequent overdose risk, improves continuation to treatment on release, and reduces recidivism. Yet most correction facilities do not follow evidence-based guidelines for treatment, resulting in destabilization and overdose. This case is unique in illustrating 1 example of a patient who is justice-involved during pregnancy and the postpartum period, and highlighting an area of advocacy that is under-reported in the medical literature. CASE PRESENTATION: A 28-year-old G2P0010 woman with a history of severe opioid use disorder (OUD) learned she was 13 weeks pregnant after a polysubstance overdose while on methadone treatment. She did not engage in prenatal care, despite many encounters with the healthcare system. Her pregnancy course was marked by polysubstance use, hospitalizations, and incarcerations. While incarcerated, she delivered a healthy baby at 37 weeks, and her parental custody rights were suspended.The obstetrics team successfully advocated with the jail for continuing methadone postpartum due to the increased risk of relapse and overdose on release. After release, she continued methadone treatment with no further illicit opioid use, began to engage in counseling, 12-step meetings, and worked towards custody of her son. CONCLUSIONS: The postpartum and postincarceration periods are 2 high-risk periods for women with OUD. OAT in and out of incarceration provided some stability and benefit, in the midst of a prenatal course that was fragmented by polysubstance use, hospitalization, and incarceration. Maintaining and prioritizing access to OAT for patients who are incarcerated is necessary, though not sufficient, to address the high risk of overdose. Empowering healthcare providers to advocate for incarcerated patients with OUD on an individual level is 1 key strategy to optimize addiction treatment for incarcerated people.