Safety and Efficacy of Buprenorphine-Naloxone in Pregnancy: A Systematic Review of the Literature.

The prevalence of opioid use among pregnant people has been increasing over the past few decades, with a parallel increase in the rate of neonatal abstinence syndrome. Opioid agonist treatment (OAT) including methadone and buprenorphine is the recommended management method for opioid use disorders during pregnancy. Methadone has been extensively studied during pregnancy; however, buprenorphine was introduced in the early 2000s with limited data on the use of different preparations during pregnancy. Buprenorphine-naloxone has been incorporated into routine practice; however, only a few studies have investigated the use of this medication during pregnancy. To determine the safety and efficacy of this medication, we conducted a systematic review of maternal and neonatal outcomes among buprenorphine-naloxone-exposed pregnancies. The primary outcomes of interest were birth parameters, congenital anomalies, and severity of neonatal abstinence syndrome. Secondary maternal outcomes included the OAT dose and substance use at delivery. Seven studies met the inclusion criteria. Buprenorphine-naloxone doses ranged between 8 and 20 mg, and there was an associated reduction of opioid use during pregnancy. There were no significant differences in gestational age at delivery, birth parameters, or prevalence of congenital anomalies between buprenorphine-naloxone-exposed neonates and those exposed to methadone, buprenorphine monotherapy, illicit opioids, or no opioids. In studies comparing buprenorphine-naloxone to methadone, there were reduced rates of neonatal abstinence syndrome requiring pharmacotherapy. These studies demonstrate that buprenorphine-naloxone is a safe and effective opioid agonist treatment for pregnant people with OUD. Further large-scale, prospective data collection is required to confirm these findings. Patients and clinicians may be reassured about the use of buprenorphine-naloxone during pregnancy.

Cannabis Use During Lactation: Literature Review and Clinical Recommendations.

Cannabis is the most commonly used psychoactive substance in Canada. The prevalence of cannabis use both during pregnancy and in the postpartum period has been estimated at 5% of the population. Women who use the drug during lactation place their infants at risk of exposure to cannabis and its metabolites in breast milk. This article provides a systematic review of infant outcomes associated with cannabis use by women during lactation followed by clinical recommendations. A review of the literature was conducted using Medline, Embase, and PsychInfo from their start to July 2018. Inclusion criteria consisted of articles addressing the impact of postpartum cannabis use by lactating women and providing developmental outcomes for infants. Two articles met these criteria and were included in our systematic review. Results indicate conflicting outcomes regarding the risk of exposure to cannabis in breast milk. Women should be advised to abstain from cannabis use during lactation or reduce consumption if abstinence is not possible. Furthermore, women should be advised to avoid breastfeeding within 1 hour of inhaled use to reduce exposure to highest concentration of cannabis in breast milk. Despite some evidence regarding health risks of post-natal exposure to cannabis, further research is needed to determine its impact on infant neurodevelopmental outcomes beyond the first year of life.

Screening, Brief Intervention, and Referral to Treatment for Prenatal Alcohol Use and Cigarette Smoking: A Survey of Academic and Community Health Care Providers.

OBJECTIVES: Prenatal alcohol and cigarette smoking are associated with numerous adverse pregnancy outcomes. Screening, Brief Intervention, and Referral to Treatment (SBIRT) represents a standardized approach; however, implementation in routine pregnancy care remains a challenge. The purpose of the study was to determine current practices, barriers to implementation, and education needs of healthcare providers utilizing SBIRT to address prenatal alcohol and cigarette smoking. METHODS: We conducted a survey of 118 providers including family physicians, midwives, and obstetricians practicing at 2 Toronto hospitals: community-based teaching site and fully affiliated academic health sciences center. RESULTS: The response rate was 79%. Almost all providers reported screening every pregnant woman for alcohol and smoking status. Brief intervention was offered by fewer providers. Education and supportive counseling were reported by a higher percentage of providers for prenatal cigarette smoking in comparison to alcohol use. Furthermore, up to 60% referred pregnant women to treatment programs for alcohol and cigarette smoking. A significantly higher number of community-based providers reported referring pregnant women to addiction treatment programs. Barriers to interventions included a perceived lack of appropriate resources, training, and clinical pathways. CONCLUSION: Healthcare providers report universal screening for prenatal alcohol and cigarette smoking; however, brief intervention and referral to treatment are more limited practices. There is a need for education of all providers regarding effective brief counseling strategies and referral to appropriate treatment resources. Development of clinical care pathways may also increase adoption of all components of SBIRT for prenatal alcohol use and cigarette smoking.

Screening and Management of Substance Use in Pregnancy: A Review.

Substance use during pregnancy has important implications for health care providers, policy makers, and can negatively impact a woman's health and the health of her children. Understanding trends, patterns of use and outcomes are critical to prevention campaigns, building awareness, and providing effective care. This review will discuss the current therapeutic approaches and recommendations for screening and patient management for substance use in pregnancy and during the postpartum period, and it is geared towards any care providers who care for patients or those who may care for patients who may be at risk for substance use during pregnancy.

No. 349-Substance Use in Pregnancy.

OBJECTIVES: To improve awareness and knowledge of problematic substance use in pregnancy and to provide evidence-based recommendations for the management of this challenging clinical issue for all health care providers. OPTIONS: This guideline reviews the use of screening tools, general approach to care, and recommendations for the clinical management of problematic substance use in pregnancy. OUTCOMES: Evidence-based recommendations for screening and management of problematic substance use during pregnancy and lactation. EVIDENCE: Updates in the literature were retrieved through searches of Medline, PubMed, and The Cochrane Library published from 1996 to 2016 using the following key words: pregnancy, electronic cigarettes, tobacco use cessation products, buprenorphine, and methadone. Results were initially restricted to systematic reviews and RCTs/controlled clinical trials. A subsequent search for observational studies was also conducted because there are few RCTs in this field of study. Articles were restricted to human studies published in English. Additional articles were located by hand searching through article reference lists. VALUES: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report. BENEFITS, HARMS, AND COSTS: This guideline is intended to increase the knowledge and comfort level of health care providers caring for pregnant women who have substance use disorders. Improved access to health care and assistance with appropriate addiction care lead to reduced health care costs and decreased maternal and neonatal morbidity and mortality.

Epidemiology and Effects of Substance Use in Pregnancy.

Substance use during pregnancy has important implications for health care providers and policymakers and can negatively affect a woman's health and the health of her children. Understanding trends, patterns of use, and outcomes are critical to developing prevention campaigns, building awareness, and providing effective care. This review critically examines the current literature on substance use in pregnancy and during the postpartum period in terms of epidemiology, risk factors, and implications. The risk factors for substance use in pregnancy, the challenges associated with reporting these cases, and the adverse effects of common substances on maternal and fetal health are discussed.

No 349 - Consommation de substances psychoactives pendant la grossesse.

OBJECTIFS: Accroître la sensibilisation à la consommation problématique de substances psychoactives pendant la grossesse et les connaissances à ce sujet, et formuler des recommandations factuelles relatives à la prise en charge de cet épineux problème clinique à l'intention de l'ensemble des fournisseurs de soins. OPTIONS: La présente directive clinique analyse l'utilisation d'outils de dépistage, l'approche générale de soins et les recommandations pour la prise en charge clinique de la consommation problématique de substances psychoactives pendant la grossesse. ISSUES: Recommandations factuelles pour le dépistage et la prise en charge de la consommation problématique de substances psychoactives pendant la grossesse et l'allaitement. RECHERCHE DOCUMENTAIRE: La littérature à jour a été obtenue au moyen de recherches dans Medline, PubMed et la Bibliothèque Cochrane visant les articles publiés entre 1996 et 2016, avec les mots clés suivants : « pregnancy ¼, « electronic cigarettes ¼, « tobacco use cessation products ¼, « buprenorphine ¼ et « methadone ¼. Les résultats ont d'abord été restreints aux analyses systématiques, aux ECR et aux essais cliniques contrôlés. Ensuite, en raison de la rareté des ECR sur le sujet, des recherches d'études observationnelles ont également été menées. Les articles sélectionnés ont été limités aux études chez l'humain publiées en anglais, puis d'autres articles ont été trouvés manuellement, par l'analyse des listes de références. VALEURS: La qualité des données a été évaluée au moyen des critères énoncés dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs. Les recommandations visant la pratique ont été classées conformément à la méthode décrite dans ce rapport. AVANTAGES, DéSAVANTAGES ET COûTS: La présente directive clinique a pour but d'améliorer les connaissances et le degré d'aisance des fournisseurs qui dispensent des soins aux femmes enceintes ayant un trouble de l'usage d'une substance. L'amélioration de l'accès aux soins de santé et de l'aide pour obtenir un traitement adéquat de la dépendance fait diminuer les coûts de santé et les taux de morbidité et de mortalité chez la mère et l'enfant. RECOMMANDATIONS.

A Comparison of Morphine Delivery in Neonatal Opioid Withdrawal.

Current estimates of the prevalence of opioid withdrawal in newborns from the 2012 Better Outcomes Registry and Network Ontario reveal that more than 4 births per 1000 display recognizable symptoms of neonatal abstinence syndrome (NAS). With a growing consensus surrounding aspects of newborn opioid withdrawal care, clinicians might agree that all infants exposed to maternal opioids require supportive observation and care to ensure appropriate adaptation and growth in the newborn period and, likewise, that there exists a smaller percentage of newborns who require additional pharmacotherapy. However, due to the dearth of comparative studies of NAS tools, there remains a lack of evidence to support the use of a specific NAS method of scoring or treatment. Two types of NAS treatment protocols currently in use include a symptom-only versus weight-based protocols. Our Neonatal Intensive Care Unit (NICU) has used both models. A formal structured NAS tool and weight-based morphine delivery system began in our NICU in 1999. We audited all newborns with known exposure to maternal opioids in our NICU from the years 2000 to 2014. The Finnegan scoring tool was used throughout all years of the chart audit. Modifications made to the Finnegan scoring tool from the MOTHER study were adapted for use in our NICU at the same time as adopting the Johns Hopkins model of symptom-only based morphine delivery in 2006. The objective of this comparative study using a retrospective chart audit is to compare length of stay (LOS) and total accumulative morphine dose across these two morphine delivery protocols. Our audit revealed that there were a significantly higher proportion of newborns in the symptom-only model that received morphine and, perhaps accordingly, also had a significantly higher LOS compared to those in the weight-based model. Comparing only those infants who did receive morphine, the comparative total accumulative dose of morphine and LOS were not significantly different between the weight-based and symptom-only morphine delivery models.

Obstetrical and neonatal outcomes of methadone-maintained pregnant women: a canadian multisite cohort study.

OBJECTIVE: To describe obstetrical and neonatal outcomes including neonatal abstinence syndrome (NAS) in a Canadian cohort of methadone-maintained pregnant women. METHODS: We conducted a retrospective chart review at three integrated care programs in Vancouver, Toronto, and Montreal. Pregnant women on methadone maintenance treatment (MMT) who attended for care between 1997 and 2009 were included in this multisite study. Maternal and neonatal outcomes in each of the three contributing centres were compared. RESULTS: A total of 94 pregnant methadone-maintained women were included in the final analysis: 36 from Toronto, 36 from Vancouver, and 22 from Montreal. Maternal demographics showed inter-site differences in ethnicity and marital status. Obstetrical complications were not frequent; the most frequent was antenatal hemorrhage, which occurred in 14% of the total cohort. The incidence of premature labour was significantly higher in Vancouver and Montreal than in Toronto. The mean gestational age at delivery for the entire cohort was 38 weeks; mean birth weight was 2856 grams. The average length of hospital stay for babies with NAS was 19 days, with 27% of neonates requiring pharmacological treatment for NAS. Approximately 60% of neonates were discharged from hospital to the care of their mother. CONCLUSION: Integrated care programs resulted in satisfactory obstetrical and neonatal outcomes for pregnant women on MMT. Policies promoting maternal-newborn contact, rooming-in, and breastfeeding may help to decrease the severity of NAS and the need for pharmacological treatment of NAS. We strongly recommend the development of similar programs across Canada to address gaps in services.

Objectif : Décrire les issues obstétricales et néonatales, y compris le syndrome d'abstinence néonatal (SAN), au sein d'une cohorte canadienne de femmes enceintes recevant un traitement de substitution à la méthadone. Méthodes : Nous avons mené une analyse de dossiers rétrospective au sein de trois programmes de soins intégrés à Vancouver, à Toronto et à Montréal. Les femmes enceintes recevant un traitement de substitution à la méthadone (TSM) qui ont sollicité les services de ces programmes entre 1997 et 2009 ont été admises à cette étude multisite. Les issues maternelles et néonatales constatées au sein de chacun des centres participants ont été comparées. Résultats : En tout, 94 femmes enceintes recevant un traitement de substitution à la méthadone ont été admises à l'analyse finale : 36 de Toronto, 36 de Vancouver et 22 de Montréal. Les caractéristiques démographiques maternelles ont révélé la présence de différences entre les programmes en matière d'ethnicité et d'état matrimonial. Les complications obstétricales n'ont pas été fréquentes : la plus fréquente a été l'hémorragie prénatale, laquelle a été constatée chez 14 % des femmes de la cohorte entière. L'incidence du travail prématuré était considérablement plus élevée à Vancouver et à Montréal qu'à Toronto. Pour l'ensemble de la cohorte, l'âge gestationnel moyen au moment de l'accouchement a été de 38 semaines; le poids denaissance moyen a été de 2 856 grammes. La durée moyenne de l'hospitalisation des nouveau-nés présentant un SAN a été de 19 jours, 27 % d'entre eux ayant nécessité une pharmacothérapie pour contrer le SAN. Environ 60 % des nouveau-nés ont été remis à leur mère à la suite de l'obtention de leur congé de l'hôpital. Conclusion : Les programmes de soins intégrés ont permis l'obtention d'issues obstétricales et néonatales satisfaisantes chez les femmes enceintes recevant un TSM. Les politiques favorisant les contacts entre la mère et le nouveau-né, le partage de la même chambre d'hôpital et l'allaitement pourraient contribuer à atténuer la gravité du SAN et la nécessité d'avoir recours à une pharmacothérapie pour contrer le SAN. Nous recommandons fortement la mise sur pied de programmes similaires partout au Canada afin de combler les écarts en matière de services.

Integrated care for pregnant women on methadone maintenance treatment: Canadian primary care cohort study.

OBJECTIVE: To describe the characteristics of a national cohort of pregnant women on methadone maintenance treatment (MMT) and to provide treatment outcome data for integrated care programs. DESIGN: Retrospective chart review. SETTING: Three different integrated care programs in geographically distinct cities: the Toronto Centre for Substance Use in Pregnancy in Toronto, Ont; the Herzl Family Practice Centre in Montreal, Que; and the Sheway clinic in Vancouver, BC. PARTICIPANTS: Pregnant women meeting criteria for opioid dependence and attending an integrated care program between 1997 and 2009. Women were excluded if they were on MMT only for chronic pain. MAIN OUTCOME MEASURES: Patient demographic characteristics, concurrent medical and psychiatric disorders, and substance use outcome data. RESULTS: A total of 102 opioid-dependent pregnancies were included. The mean age was 29.7 years and 64% of women were white. Women in Montreal were more likely to have partners and had fewer children. Differences in living and housing situations among the sites tended to resolve by the time of delivery. Almost half of this cohort tested positive for hepatitis C. Women had a high prevalence of depression and anxiety across all sites. Half of this cohort was on MMT before conception and for the other half, MMT was initiated at a mean gestational age of 20.7 weeks, resulting in a mean dose of 82.4 mg at delivery. At the first visit, polysubstance use was common. Prescription opioid use was more frequent in Toronto and heroin use was more prevalent in Vancouver and Montreal. For the entire population, significant reductions were found by the time of delivery for illicit (P < .001) and prescription opioids (P = .001), cocaine (P < .001), marijuana (P = .009), and alcohol use (P < .001). CONCLUSION: Despite geographic differences, all 3 integrated care programs have been associated with significant decreases in substance use in pregnant opioid-dependent women.

Neonatal abstinence syndrome clinical practice guidelines for Ontario.

Ontario's clinical practice guidelines for neonatal abstinence syndrome (NAS) provide evidence-informed recommendations that address the needs of substance using pregnant women and newborns at risk of NAS. NAS is a complex and multifaceted issue that is escalating along with rapidly rising opioid use in Ontario. Reducing the incidence and impact of NAS requires immediate action in order to improve the care of affected women and infants. This includes optimizing and standardizing treatment strategies, assessing and managing social risk, better monitoring of prescribing practices and facilitating the implementation of better treatment and prevention strategies as they become available. These clinical practice guidelines provide the framework to inform and support the development of a coordinated strategy to address this important issue and to promote safe and effective care.

The opioid dependent mother and newborn- an update. The 6th Annual Ivey Symposium.

The sixth Ivey Chair Symposium, held at the University of Western Ontario in October 2011, was dedicated to an update on the complex issues surrounding opioid dependent mothers and their newborns. The day commenced with Loretta Finnegan who provided a historical overview of the complex issues surrounding the addicted mother and her baby suffering from neonatal withdrawal syndrome. It is remarkable that the tool devised by Dr Finnegan forty years ago is in wide use today, capturing accurately the severity of NAS and the need for follow up and treatment. She stressed that comprehensive approach to the care of pregnant drug-dependent mothers and their babies significantly reduces maternal and infant's morbidity. The risk of low birth weight and severe withdrawal can be reduced substantially when both patients in this dyad are optimally cared for. The seven speakers following her provided an update on the medicinal and non drug approach to treat the opioid-dependent mother and her newborn, including new Canadian guidelines which were just released. 

Comprehensive treatment program for pregnant substance users in a family medicine clinic.

PROBLEM BEING ADDRESSED: Substance use during pregnancy is a substantial public health problem and a risk factor for poor neonatal outcomes. Prenatal care is often provided in high-risk pregnancy units, separate from addiction treatment. OBJECTIVE OF PROGRAM: To provide comprehensive prenatal care and addiction treatment in a family medicine setting. DESCRIPTION OF PROGRAM: The Toronto Centre for Substance Use in Pregnancy (T-CUP) is a family medicine-based program in a large urban city in Ontario. The T-CUP program comprises an interdisciplinary team using a one-stop access model to provide comprehensive services for pregnant women with a history of alcohol or drug abuse, including prenatal and postnatal medical care, addiction counseling, and assistance with complex psychosocial needs. EVALUATION: A retrospective chart review was performed, including charts for 121 women who received care at T-CUP from August 2000 to January 2006. Women demonstrated a high compliance rate with prenatal care attendance. Most women reported reduction in a variety of drug use categories. Significant differences were found especially among women who presented earlier in their pregnancies (P < .05). As a result, neonatal outcomes were satisfactory and approximately 75% of newborns were discharged home in the care of their mothers. CONCLUSION: Pregnant substance-using women have positive maternal and infant health outcomes when they receive comprehensive care in a family medicine setting.

Efficacy of a physicians' pocket guide about prenatal substance use: a randomized trial.

A pocket guide on management of substance use during pregnancy was developed by a group of Canadian care providers. One hundred and fifteen family medicine residents in 6 Canadian teaching sites were randomized to receive either the pocket guide or a paper summary on similar clinical topics, based on UpToDate, a comprehensive Web-based resource. At baseline, both groups completed a survey containing questions on beliefs, attitudes, experience, and training on pregnancy and substance use. Participants then answered 28 multiple choice questions about substance use in pregnancy, using either the pocket guide or UpToDate. Finally participants were asked to rate ease of use for the 2 resources. The results showed that the pocket guide group had higher knowledge scores than the UpToDate group overall and at each study site (61.27% vs. 42.86%, P < .001). The residents found the pocket guide easier to use than UpToDate (mean = 2.73 vs. 4.36, P < .001), and were more likely to want to use it again (96% for pocket card, 78% for UpToDate, P = .005). It is concluded that the pocket guide is a practical source of clinical information at point of care, particularly for "orphan" subjects such as substance use in pregnancy.

SOGC clinical practice guidelines: Substance use in pregnancy: no. 256, April 2011.

OBJECTIVE: To improve awareness and knowledge of problematic substance use in pregnancy and to provide evidence-based recommendations for the management of this challenging clinical issue for all health care providers. OPTIONS: This guideline reviews the use of screening tools, general approach to care, and recommendations for clinical management of problematic substance use in pregnancy. OUTCOMES: Evidence-based recommendations for screening and management of problematic substance use during pregnancy and lactation. EVIDENCE: Medline, PubMed, CINAHL, and The Cochrane Library were searched for articles published from 1950 using the following key words: substance-related disorders, mass screening, pregnancy complications, pregnancy, prenatal care, cocaine, cannabis, methadone, opioid, tobacco, nicotine, solvents, hallucinogens, and amphetamines. Results were initially restricted to systematic reviews and randomized control trials/controlled clinical trials. A subsequent search for observational studies was also conducted because there are few RCTs in this field of study. Articles were restricted to human studies published in English. Additional articles were located by hand searching through article reference lists. Searches were updated on a regular basis and incorporated in the guideline up to December 2009. Grey (unpublished) literature was also identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table 1). BENEFITS, HARMS, AND COSTS: This guideline is intended to increase the knowledge and comfort level of health care providers caring for pregnant women who have substance use disorders. Improved access to health care and assistance with appropriate addiction care leads to reduced health care costs and decreased maternal and neonatal morbidity and mortality.

Substance use in pregnancy.

OBJECTIVE: To improve awareness and knowledge of problematic substance use in pregnancy and to provide evidence-based recommendations for the management of this challenging clinical issue for all health care providers. OPTIONS: This guideline reviews the use of screening tools, general approach to care, and recommendations for clinical management of problematic substance use in pregnancy. OUTCOMES: Evidence-based recommendations for screening and management of problematic substance use during pregnancy and lactation. EVIDENCE: Medline, PubMed, CINAHL, and The Cochrane Library were searched for articles published from 1950 using the following key words: substance-related disorders, mass screening, pregnancy complications, pregnancy, prenatal care, cocaine, cannabis, methadone, opioid, tobacco, nicotine, solvents, hallucinogens, and amphetamines. Results were initially restricted to systematic reviews and randomized control trials/controlled clinical trials. A subsequent search for observational studies was also conducted because there are few RCTs in this field of study. Articles were restricted to human studies published in English. Additional articles were located by hand searching through article reference lists. Searches were updated on a regular basis and incorporated in the guideline up to December 2009. Grey (unpublished) literature was also identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table 1). BENEFITS, HARMS, AND COSTS: This guideline is intended to increase the knowledge and comfort level of health care providers caring for pregnant women who have substance use disorders. Improved access to health care and assistance with appropriate addiction care leads to reduced health care costs and decreased maternal and neonatal morbidity and mortality. RECOMMENDATIONS: 1. All pregnant women and women of childbearing age should be screened periodically for alcohol, tobacco, and prescription and illicit drug use. (III-A) 2. When testing for substance use is clinically indicated, urine drug screening is the preferred method. (II-2A) Informed consent should be obtained from the woman before maternal drug toxicology testing is ordered. (III-B) 3. Policies and legal requirements with respect to drug testing of newborns may vary by jurisdiction, and caregivers should be familiar with the regulations in their region. (III-A) 4. Health care providers should employ a flexible approach to the care of women who have substance use problems, and they should encourage the use of all available community resources. (II-2B) 5. Women should be counselled about the risks of periconception, antepartum, and postpartum drug use. (III-B) 6. Smoking cessation counselling should be considered as a first-line intervention for pregnant smokers. (I-A) Nicotine replacement therapy and/or pharmacotherapy can be considered if counselling is not successful. (I-A) 7. Methadone maintenance treatment should be standard of care for opioid-dependent women during pregnancy. (II-IA) Other slow-release opioid preparations may be considered if methadone is not available. (II-2B) 8. Opioid detoxification should be reserved for selected women because of the high risk of relapse to opioids. (II-2B) 9. Opiate-dependent women should be informed that neonates exposed to heroin, prescription opioids, methadone, or buprenorphine during pregnancy are monitored closely for symptoms and signs of neonatal withdrawal (neonatal abstinence syndrome). (II-2B) Hospitals providing obstetric care should develop a protocol for assessment and management of neonates exposed to opiates during pregnancy. (III-B) 10. Antenatal planning for intrapartum and postpartum analgesia may be offered for all women in consultation with appropriate health care providers. (III-B) 11. The risks and benefits of breastfeeding should be weighed on an individual basis because methadone maintenance therapy is not a contraindication to breastfeeding. (II-3B).

Buprenorphine: new treatment of opioid addiction in primary care.

OBJECTIVE: To review the use of buprenorphine for opioid-addicted patients in primary care. QUALITY OF EVIDENCE: The MEDLINE database was searched for literature on buprenorphine from 1980 to 2009. Controlled trials, meta-analyses, and large observational studies were reviewed. MAIN MESSAGE: Buprenorphine is a partial opioid agonist that relieves opioid withdrawal symptoms and cravings for 24 hours or longer. Buprenorphine has a much lower risk of overdose than methadone and is preferred for patients at high risk of methadone toxicity, those who might need shorter-term maintenance therapy, and those with limited access to methadone treatment. The initial dose should be given only after the patient is in withdrawal. The therapeutic dose range for most patients is 8 to 16 mg daily. It should be dispensed daily by the pharmacist with gradual introduction of take-home doses. Take-home doses should be introduced more slowly for patients at higher risk of abuse and diversion (eg, injection drug users). Patients who fail buprenorphine treatment should be referred for methadone- or abstinence-based treatment. CONCLUSION: Buprenorphine is an effective treatment of opioid addiction and can be safely prescribed by primary care physicians.

Participant perception of an integrated program for substance abuse in pregnancy.

OBJECTIVE: To assess participant perception of an integrated model of care for substance abuse in pregnancy. DESIGN: Focus groups were employed for this qualitative study. SETTING: Two Family Medicine Units, 1 in Toronto and 1 in Montreal, where integrated care for licit and illicit substance abuse in pregnancy is provided by a team of doctors, nurses, nurse practitioners, and social workers. PARTICIPANTS: Women who had received addiction and prenatal care at 1 of the 2 sites. METHODS: Women were asked to discuss their experiences of care in focus groups. RESULTS: Five central themes emerged: judgment, physician-patient communication, team communication, support groups, and self-responsibility. CONCLUSION: Women felt more comfortable with provider teams that shared a consistent nonjudgmental attitude.

Short-term outcomes in patients attending a primary care-based addiction shared care program.

OBJECTIVE: To evaluate patient outcomes in an addiction shared care program that is managed by family physicians working in a primary care setting. DESIGN: Prospective cohort study. SETTING: The addiction shared care program at St Joseph's Health Centre in Toronto, Ont, which is staffed by a nurse clinician, an addiction therapist, a clinical fellow, and 6 family physicians in an academic family medicine unit. PARTICIPANTS: Participants included patients who attended at least one session in the program. The patients were self-referred or referred by family doctors, government agencies, or the emergency department. INTERVENTIONS: The service provided brief counseling interventions, outpatient medical detoxification, pharmacotherapy, and follow-up, and there was communication with the referring family physicians. MAIN OUTCOME MEASURES: Changes in self-reported substance use were measured through interviews at intake and at 3 to 4 months after the initial office visit. RESULTS: The study was conducted between January 2005 and April 2006. Out of 204 patients who gave consent to participate at baseline, we interviewed 71 patients about 4 months later. Among 33 problem drinkers, the mean number of standard drinks consumed per week declined from 32.9 at baseline to 9.6 at follow-up (P < .0005). Of the 29 problem opioid users, 6 were started on methadone treatment and 13 had decreased their opioid consumption from a mean morphine equivalent of 168.38 mg to 70.85 mg daily (P = .001). There was also a significant decline in the problematic use of benzodiazepines (P = .004) and other drugs (P = .005), but there was no significant decline in the problematic use of cannabis or cocaine. Twenty-two patients (31%) participated in Alcoholics Anonymous or formal addiction treatment. CONCLUSION: Shared care is a promising new strategy for delivering addiction intervention. Further evaluation is warranted, with more complete follow-up and objective outcome measures.