Do maternal opioids reduce neonatal regional brain volumes? A pilot study.

OBJECTIVE: A substantial number of children exposed to gestational opioids have neurodevelopmental, behavioral and cognitive problems. Opioids are not neuroteratogens but whether they affect the developing brain in more subtle ways (for example, volume loss) is unclear. We aimed to determine the feasibility of using magnetic resonance imaging (MRI) to assess volumetric changes in healthy opioid-exposed infants. STUDY DESIGN: Observational pilot cohort study conducted in two maternity hospitals in New South Wales, Australia. Maternal history and neonatal urine and meconium screens were obtained to confirm drug exposure. Volumetric analysis of MRI scans was performed with the ITK-snap program. RESULT: Scans for 16 infants (mean (s.d.) gestational age: 40.9 (1.5) weeks, birth weight: 3022.5 (476.6) g, head circumference (HC): 33.7 (1.5 cm)) were analyzed. Six (37.5%) infants had HC <25th percentile. Fourteen mothers used methadone, four used buprenorphine and 11 used more than one opioid (including heroin, seven). All scans were structurally normal whole brain volumes (357.4 (63.8)) and basal ganglia (14.5 (3.5)) ml were significantly smaller than population means (425.4 (4.8), 17.1 (4.4) ml, respectively) but lateral ventricular volumes (3.5 (1.8) ml) were larger than population values (2.1(1.5)) ml. CONCLUSION: Our pilot study suggests that brain volumes of opioid-exposed babies may be smaller than population means and that specific regions, for example, basal ganglia, that are involved in neurotransmission, may be particularly affected. Larger studies including correlation with neurodevelopmental outcomes are warranted to substantiate this finding.

Clinical characteristics of central European and North American samples of pregnant women screened for opioid agonist treatment.

BACKGROUND: Little comparable information is available regarding clinical characteristics of opioid-dependent women from different countries. In the present study, women from the USA, Canada and a Central European country, Austria, screened for participation in the Maternal Opioid Treatment Human Experimental Research study, were compared with respect to their demographic and addiction histories. METHODS: Pregnant women (n = 1,074) were screened for study participation using uniformed clinical criteria and instruments. The screening results were compared with regard to exclusion, demographics, drug use, and psychosocial and treatment histories. RESULTS: Compared to the screened US and Canadian women, Austrian women were more likely to be younger (p < 0.001), white (p < 0.001), had significantly lower levels of educational attainment (p < 0.001), were less likely to use opioids daily (p < 0.001) and more likely to have been prescribed buprenorphine (p < 0.001). Compared to both rural and urban US groups, the Austrian group was less likely to have legal issues (p < 0.001) and was younger when first prescribed agonist medication (p < 0.001). CONCLUSION: The differences between North American and European groups may offer unique insights concerning treatment and pregnancy outcomes for opioid-dependent pregnant women.

Smoking in pregnant women screened for an opioid agonist medication study compared to related pregnant and non-pregnant patient samples.

BACKGROUND: Little is known about the prevalence and severity of smoking in pregnant opioid dependent patients. OBJECTIVES: To first characterize the prevalence and severity of smoking in pregnant patients screened for a randomized controlled trial, Maternal Opioid Treatment: Human Experimental Research (MOTHER), comparing two agonist medications; and second, to compare the MOTHER screening sample to published samples of other pregnant and/or patients with substances use disorders. METHODS: Pregnant women (N = 108) screened for entry into an agonist medication comparison study were retrospectively compared on smoking variables to samples of pregnant methadone-maintained patients (N = 50), pregnant opioid or cocaine dependent patients (N = 240), non-pregnant methadone-maintained women (N = 75), and pregnant non-drug-addicted patients (N = 1,516). RESULTS: Of screened patients, 88% (n = 95) smoked for a mean of 140 months (SD = 79.0) starting at a mean age of 14 (SD = 3.5). This rate was similar to substance use disordered patients and significantly higher compared to general pregnant patients (88% vs. 22%, p < .001). CONCLUSION AND SCIENTIFIC SIGNIFICANCE: Aggressive efforts are needed to reduce/eliminate smoking in substance-abusing pregnant women.

The effects of maternal cocaine abuse on mothers and newborns.

Recent studies indicate a complex picture of the effects of maternal cocaine abuse with the majority of negative outcomes a result of dose response effects and cumulative risk factors. This paper reviews recent research within a historic perspective and provide an overview of current knowledge of perinatal outcomes, including neurobehavioral effects and the effect of treatment on mothers and newborns.

A search for strategies to engage women in substance abuse treatment.

Retention is a well-documented predictor of favorable outcome of substance abuse treatment. In order to remain in treatment, clients must initially engage in the treatment process. This issue is a particular challenge for clinicians who continually seek motivational strategies that will draw each individual into the treatment process. Few engagement strategies have been specifically tested to determine their efficacy. The results of this study indicate that outpatient clients who received engagement services during the intake period showed increased use of these services, relative to a comparison group, throughout the treatment process. In addition, tangible engagement services provided to women during the intake period for outpatient substance abuse treatment had no significant effect on the rates of admission, discharge, and service utilization.

Biopsychosocial characteristics and treatment outcomes of pregnant cocaine-dependent women in residential and outpatient substance abuse treatment.

The purpose of this descriptive study was to compare the characteristics and treatment outcomes of pregnant cocaine-dependent women and their infants enrolled in residential (N=32) and outpatient (N=32) treatment settings. Biopsychosocial characteristics and issues that influenced the women's multiple treatment outcomes are highlighted. Comparisons of retention and infant birth outcomes found no significant differences between treatment programs, whereas abstinence and patterns of attrition showed meaningful differences favoring residential treatment. Further research is needed to evaluate whether the reported treatment outcomes are markers of improved life functioning that hold promise for the women in treatment, their families and the community.

Assessing the needs of substance abusing women. Psychometric data on the psychosocial history.

The Psychosocial History (PSH) is a comprehensive multidisciplinary interview designed to assess the status, history, and needs of women in substance abuse treatment. The PSH retains the fundamental scoring structure of the Addiction Severity Index (ASI), while adding supplemental questions considered clinically useful and relevant for predicting outcomes. The present study examined the psychometric properties and general utility of both instruments with a sample of women enrolled in substance abuse treatment. Initially, the instruments were tested independently and found to have excellent test-retest reliability and acceptable internal consistency. A reliability trial between the instruments found that the composite scores (CS) of the ASI and PSH yielded satisfactory correlations among four of the six CS domains. The PSH had higher CS scores than the ASI across domains, which may reflect the comprehensive nature of the PSH items that prompt greater disclosure of problems and needs. Validity analyses showed significant correlations of PSH and ASI psychiatric CSs with Symptom Checklist-90-Revised totals. These results suggest that the PSH yields reliable and valid assessment data similar to the ASI. Moreover, the PSH provides a more comprehensive assessment than the ASI in the area of pregnancy, family issues, and victimization.

Prevention and treatment issues for pregnant cocaine-dependent women and their infants.

The increase in cocaine use among pregnant women has created significant challenges for treatment providers. Drug dependent women tend to neglect general health and prenatal care. Perinatal management is often difficult due to medical, obstetrical, and psychiatric complications. Research has demonstrated that comprehensive care, including high risk obstetrical care, psychosocial services, and addiction treatment can reduce complications associated with perinatal substance abuse. Research investigating the effectiveness of residential and outpatient treatment for pregnant cocaine-dependent women also suggests that many biopsychosocial characteristics and issues influence treatment outcomes. Homelessness and psychiatric illness require a more intensive level of care, and abstinence is difficult to maintain for many women in outpatient treatment as they continue to live in drug-using environments. To optimize the benefit of comprehensive services, services should be provided within a multilevel model of substance abuse treatment including long- and short-term residential, intensive outpatient, and outpatient settings.

Opioid dependence during pregnancy. Effects and management.

This article describes the complex problems associated with opioid dependence during pregnancy. Medical, obstetric, and psychosocial problems are presented. Methadone maintenance for the treatment of opioid dependence is described in this article. Specific issues of appropriate methadone dose during pregnancy, medical withdrawal, and the relationship of methadone dose and the severity of neonatal abstinence also are discussed.

Women in recovery. Their perceptions of treatment effectiveness.

Research with chemically dependent women over the past two decades indicates that women substance abusers have special characteristics and needs that warrant gender-sensitive drug-treatment approaches. While the potential benefit of such treatment seems clear, little empirical data is available on how women perceive the effectiveness of gender-sensitive specialized drug treatment. This article presents findings from an exploratory study of the present and past treatment experiences of 24 women in recovery. Results indicate that while some specialized services such as child care and women-only therapy groups are increasingly available, many drug-treatment programs fail to provide these services in a context which supports and promotes women. As a result, women in drug treatment continue to experience negative stereotyping and sexual harassment as their gender-specific needs remain ignored, silenced, or deemed pathological. Major gaps in drug treatment for women are discussed as are implications for the provision of effective gender-sensitive treatment.

Effects of in-utero opiate exposure: new paradigms for old questions.

The purpose of this paper is to present an overview of existing research on prenatal opiate exposure, identifying limitations of past work and in so doing provide a useful paradigm for contemporary investigations. Initial opiate exposure research in the 70's and early 80's typically employed a bi-variate approach with little or no attention to multiple confounding factors. By the mid-80's most researchers recognized that not only biological but social and environmental risk factors must be considered and began to call for a multi-factorial approach to investigate perinatal and developmental outcomes associated with prenatal opiate exposure. However, concurrent with this direction toward a multivariate approach, prenatal cocaine exposure became a priority and funding interest in the effects of opiates began to wane. Unfortunately, rather than employ the model emerging from the experience of opiate investigations, initial research directed at identifying effects of cocaine exposure often employed the same type of bi-variate approach, naive to the cumulative risks concomitant to maternal substance abuse. Subsequently, one is left with a sense of de ja vu as researchers investigating the effects of prenatal cocaine exposure begin to recognize the complexity of delineating the effects of prenatal drug exposure and the need to address multiple confounding factors. It is within this context that an overview of existing research on prenatal opiate exposure will be presented with the hope that the limitations of the past can be used to construct a useful paradigm for the future.(ABSTRACT TRUNCATED AT 250 WORDS)

Health care clusters in hospitals: the market audit and frameworks for planning.

Many hospitals are turning to cluster relationships to gain the benefits of diversification without the troubles of increased capital costs and management conflicts. The goal of healthcare clusters is to provide a continuum of care to a defined geographic region through integration of referral and payment systems. To aid in successful planning for healthcare clusters, a market audit and frameworks for examining the current healthcare market are presented.

Prenatal narcotic exposure: perinatal and developmental effects.

Infants prenatally exposed to narcotics become passively addicted in-utero and may undergo neonatal abstinence at birth. Methadone maintenance in conjunction with intensive prenatal care for pregnant narcotic dependent women can reduce the incidence of intrauterine death, neonatal death, prematurity and its concomitant problems. However, methadone exposed infants have consistently been found to have smaller birthweights and head circumference than non-drug exposed infants. Although neonatal abstinence can be treated successfully with pharmacotherapy, the effects of in-utero narcotic exposure in the developing central nervous system are not fully understood. Infants exposed to narcotics in-utero have been found to have slit-like ventricles with smaller lateral ventricle and intracranial hemidiameter measurements during the first month of life. The incidence of strabismus is also greater in infants exposed to narcotics in-utero than the general population, but this appears to be related to lower birth weight, rather than a direct consequence of narcotic exposure. There does not appear to be developmental sequelae associated with prenatal narcotic exposure. After abstinence has abated, infants function well within the normal range of development during the first two years of life, although developmental scores may be lower than non-drug exposed comparisons groups. There are a myriad of confounding medical, pharmacological and environmental variables within this population and the relative importance of prenatal narcotic exposure in a continuum of risk factors needs to be more clearly delineated before the etiology of perinatal and developmental effects can be determined.

Perinatal and developmental outcome of infants exposed to methadone in-utero.

The purpose of this research is to delineate the effects of methadone exposure in-utero. Subjects were 141 infants born to drug dependent women maintained on methadone during pregnancy and 127 non-drug exposed comparison infants matched for race, maternal age, and socioeconomic status. Methadone exposed infants had smaller birth weights than comparison infants. Differences were also found in head circumference. However, this difference was not clinically significant but rather reflects the relationship between birth weight and head circumference. No difference was found between groups in mental development. One hundred and five methadone exposed infants and 63 comparison infants were evaluated with the Bayley Scale of Mental Development at 6 months of age. Mean Bayley Mental Development scores for methadone exposed infants and comparison infants were 103 and 105 respectively. These data suggest that while methadone exposure in-utero is associated with lower birth weight and head circumference, by six months of age, these infants do not exhibit any general developmental sequelae.