Trends in maternal opioid use disorder and neonatal abstinence syndrome in Maine, 2016-2022.

OBJECTIVE: To estimate trends in maternal opioid use disorder (OUD) and neonatal abstinence syndrome (NAS) in Maine using the most recent data available. STUDY DESIGN: We used hospital discharge data to estimate the annual prevalence of maternal OUD and NAS between 2016 and 2022. In addition, we used birth certificate-linked Medicaid data to estimate related trends among Medicaid enrollees. RESULT: From 2016 to 2022, the prevalence of maternal OUD decreased from 35.3 to 18.8 per 1000 deliveries and the prevalence of NAS decreased from 33.2 to 14.0 per 1000 newborns (linear trend p values <0.01). Decreasing trends were also found among Medicaid enrollees. CONCLUSION: In Maine between 2016 and 2022, there was a decrease in maternal OUD and NAS diagnoses recorded in administrative datasets. These findings should be interpreted with caution due to changes in how OUD and NAS diagnoses are recorded and COVID-related changes in healthcare utilization.

Hepatitis C Virus Cascade of Care Among Perinatal Patients in Maine Diagnosed With Opioid Use Disorder, 2015-2020.

OBJECTIVE: This is a quality improvement project to determine the best process to identify and address gaps in care for perinatal patients in receiving appropriate hepatitis C virus (HCV) testing and treatment across the largest health system in Maine. STUDY DESIGN: We reviewed electronic medical record data between October 1, 2015, and February 1, 2020, to investigate rates of HCV testing and treatment among 916 perinatal patients with opioid use disorder across 8 hospitals using a "cascade of care" framework, a model used previously to identify gaps in care and treatment of chronic diseases. MAIN OUTCOME MEASURE: We examined HCV testing and treatment rates along the cascade of care and patient characteristics associated with HCV antibody testing and treatment, separately, using log binomial regression models. Models were adjusted for age, residential distance to medical center, psychiatric diagnosis, and opioid agonist therapy at delivery. RESULTS: Of pregnant patients eligible for screening, 64% (582/916) received HCV antibody testing. Of 136 patients with active HCV infection, 32% (n = 43) received a referral for treatment, 21% (n = 28) were treated, and 13% (n = 18) achieved sustained virologic response. In the adjusted regression models, only opioid agonist therapy was associated with HCV antibody testing (adjusted risk ratio, 1.31; 95% confidence interval, 1.18-1.46), and no factors were significantly associated with receipt of treatment among HCV viremic patients. CONCLUSION: Low referral and treatment rates signify the need for quality improvement interventions to improve coordination of care between multiple disciplines and practice settings to increase access to HCV treatment.

Peripartum and Postpartum Analgesia and Pain in Women Prescribed Buprenorphine for Opioid Use Disorder Who Deliver by Cesarean Section.

Aim: Little is known about whether pain can be effectively managed in pregnant women with opioid use disorder (OUD) during delivery hospitalization, particularly those undergoing surgery and taking buprenorphine as medication for OUD (MOUD). To address this question, we compared pain scores and opioid analgesic utilization during delivery hospitalization in women taking their pre-hospital dose of buprenorphine who delivered by cesarean section to matched controls. To inform future research efforts, we also began to explore opioid analgesic utilization and pain scores by type of anesthesia as this variable is often not included in related literature. Methods: Retrospective matched cohort study of 46 women prescribed buprenorphine during pregnancy who delivered by cesarean section during a 7-year period. Results: When compared to matched controls, women taking their pre-hospital dose of buprenorphine undergoing cesarean section utilized more opioid analgesics as measured by morphine milligram equivalents (MME) (mean MME first 48 hours 153.0 mg vs 175.1 mg, respectively, P < .01) but had similar pain scores during delivery hospitalization. There was no difference in MME utilization by maternal dose of buprenorphine though sample sizes were small. Women on buprenorphine who received spinal anesthesia with morphine had mean pain scores that were 1.4 points lower (P = .01) during the first 48 hours than women on buprenorphine receiving other methods of anesthesia. Discussion And Conclusions: Pregnant women taking their pre-hospital dose of buprenorphine throughout their surgical delivery hospitalization were able to achieve pain relief similar to women not on MOUD but had higher MME requirements. Our results add to the emerging body of evidence suggesting that individuals on MOUD can achieve adequate post-surgical pain management without adjusting their pre-hospital dose of buprenorphine. Further research is required to fully understand the optimal buprenorphine dosing regimen during surgical hospitalizations. Our results also provide important preliminary evidence that spinal anesthesia containing opioids can be used effectively in individuals with OUD requiring surgical intervention.

Medication for Addiction Treatment and Postpartum Health Care Utilization Among Pregnant Persons With Opioid Use Disorder.

OBJECTIVE: To estimate treatment and postpartum health care utilization among pregnant persons with opioid use disorder (OUD) in Vermont and Maine. METHODS: Vermont's and Maine's All Payer Claims Databases were used to identify deliveries 2010 to 2018 that were paid for, in part, by Medicaid. OUD was identified among pregnant persons if they had any claim with an OUD-diagnosis code (ICD-9/10) or medication for addiction treatment (MAT) code during the 5 months before delivery event. Consistent and inconsistent MAT were compared to no MAT on the rate of hospitalizations and emergency department (ED) visits in the first 12 months' postpartum using negative binomial regression. RESULTS: From 2010 through 2018, 27,652 deliveries in Vermont and 43,480 deliveries in Maine were among persons insured by Medicaid. The prevalence of OUD among pregnant persons increased from 6.7% to 11.6% in Vermont and from 7.4% to 11.0% in Maine. Among pregnant persons with OUD in 2018, 57% had consistent MAT in Vermont and 50% had consistent MAT in Maine; approximately 32% and 27% were not in treatment in Vermont and Maine, respectively. In Maine, consistent MAT was associated with a 47% lower rate of hospitalization and 37% to 46% lower rates of ED visits when compared to those without MAT; in Vermont, those with consistent buprenorphine treatment had a 30% lower rate of ED visits. CONCLUSIONS: Medicaid data from Vermont and Maine suggests that medication for addiction treatment for opioid use disorder during pregnancy reduces emergency health care utilization in the first year postpartum.

Experiences of stigma among individuals in recovery from opioid use disorder in a rural setting: A qualitative analysis.

INTRODUCTION: Stigma is a barrier to accessing treatment and support services for individuals with substance use disorder. Stigma is negatively associated with completion of treatment for substance use disorder and management of recovery. OBJECTIVE: To learn from individuals in recovery from opioid use disorder in a largely rural area about how their personal experiences of stigma affected their ability to enter into treatment and stay in recovery. METHODS: We conducted ten focus group sessions with established cohorts of individuals in recovery who met regularly as part of recovery programs in central Maine, including two cohorts of postpartum women. Focus groups included 58 participants (33 women and 25 men, age > 18). We conducted a content analysis of focus group transcripts. RESULTS: Study participants identified hospitals, government agencies, and pharmacies as the primary locations where they had stigmatizing experiences. Participants identified pharmacists and pharmacy technicians as the most frequent perpetrators of stigma. Participants identified fear and secrecy as pathways through which stigma negatively affected their recovery. CONCLUSION: Anti-stigma training programs and related efforts conducted in rural areas may benefit from including pharmacists and pharmacy technicians in training activities, and from considering hospital, government agency, and pharmacy settings as venues for anti-stigma interventions.

Implications of perinatal buprenorphine exposure on infant head circumference at birth.

Objective: To determine the potential impact of prenatal buprenorphine exposure on head circumference at birth and analyze whether head circumference may be related to maternal buprenorphine dose at delivery, delayed maternal entry into buprenorphine treatment or exposure to a variety of other medications and substances.Methods: A retrospective cohort study was performed of 137 full-term infants exposed to buprenorphine during pregnancy from January 2013 to December 2017. Pearson's correlation was calculated to investigate the potential relationship between head circumference and maternal dose of buprenorphine at delivery. t-tests were conducted to analyze head circumference in relationship to dichotomous variables.Results: Head circumference in infants exposed to buprenorphine during pregnancy was not significantly different from national norms for either male infants (95% CI 28.2-33.5 cm, norm 31.5 cm, and 28.5-34.9 cm, norm 33.1 cm, for the 3rd and 10th percentile, respectively) or female infants (95% CI 28.7-32.8 cm, norm 31.9 cm, and 29.1-34.3, norm 32.8 cm for the 3rd and 10th percentile, respectively). Head circumference was not associated with delayed maternal entry into buprenorphine treatment (t = -1.0715, p = .287) or exposure to psychotropic medications during pregnancy (t = 0.4194, p = .677). There was no relationship between infant head circumference and maternal buprenorphine dose at delivery (r = 0.004, p = .967). Head circumference was not associated with maternal smoking (t = 0.003, p = .998) or exposure to marijuana (t = 0.7277, p = .468), illicit opioids (t = -0.6701, p = .504), illicit amphetamines (t = -0.4062, p = .687) or illicit benzodiazepines (t = -0.6288, p = .535) during pregnancy.Conclusions: Exposure to buprenorphine prenatally does not appear to be associated with reduced head circumference at birth. Head circumference at birth also does not appear related to either maternal buprenorphine dose at delivery or delayed entry into treatment. As previous literature suggests that high dose methadone exposure during pregnancy may be associated with smaller head circumference and that smaller head circumference may be associated with risk of neurocognitive disorders, our results further support the use of buprenorphine as a first line treatment for opioid use disorders during pregnancy.

Initial Management of Incarcerated Pregnant Women With Opioid Use Disorder.

The epidemic of opioid and other drug use and related arrests are a growing public health crisis in the United States. The national prevalence of pregnant women with opioid use disorder (OUD) has increased dramatically from 1.5 per 1,000 delivery hospitalizations in 1999 to 6.5 in 2014. The combination of these factors has led to an increased frequency of pregnant women with OUDs in the correctional health care system. This protocol provides evidence-based treatment recommendations including the initiation of methadone and buprenorphine in the inpatient or jail setting. It also explores many of the nuances around caring for this vulnerable patient population and discusses ways in which the medical and correctional health care teams can efficiently collaborate to improve patient outcomes.

Predictors of treatment retention in postpartum women prescribed buprenorphine during pregnancy.

AIM: To determine variables related to treatment retention in women six and twelve months postpartum that were in medication treatment using buprenorphine during pregnancy. METHODS: This retrospective cohort study of 190 maternal-infant dyads exposed to buprenorphine during pregnancy examines rates of treatment retention at six and twelve months postpartum and also analyzes a variety of potential predictors of treatment retention including illicit drug use in the third trimester, delayed entry into medication treatment and co-occurring mental health diagnoses requiring prescription medication. RESULTS: At 12months postpartum, women appeared more likely to remain in medication treatment if they entered treatment early in pregnancy (defined as either being in treatment at the time of conception, p=0.001, or entering medication treatment prior to 13weeks gestation, p=0.037). Being prescribed an antidepressant medication during the third trimester was also associated with enhanced treatment retention at six months postpartum (p=0.005). At both six and twelve months postpartum, the use of illicit drugs (including opioids, cocaine and benzodiazepines) during the third trimester was negatively correlated with treatment retention (p=0.012 and p<0.001, respectively). CONCLUSIONS: Early access to medication treatment is associated with treatment retention in women prescribed buprenorphine during pregnancy. This has important public health implications as access to treatment is limited in many parts of the country and many women are only able to obtain treatment after becoming pregnant. Being prescribed an antidepressant medication during pregnancy may enhance treatment retention, supporting the work of previous authors.

Maternal and infant outcomes following third trimester exposure to marijuana in opioid dependent pregnant women maintained on buprenorphine.

BACKGROUND: To determine whether maternal and infant outcomes are associated with exposure to marijuana during the third trimester in a population of opioid dependent pregnant women maintained on buprenorphine. METHODS: This retrospective cohort study of 191 maternal-infant dyads exposed to buprenorphine during pregnancy examines a variety of variables including gestational age, birthweight, method of delivery, Apgar scores at one and five minutes, duration of infant hospital stay, peak neonatal abstinence syndrome (NAS) score, duration of NAS and incidence of pharmacologic treatment of NAS in infants exposed to marijuana during the third trimester as compared to infants not exposed to marijuana during the third trimester. RESULTS: Analyses failed to support any significant relationship between marijuana use in the third trimester and a variety of maternal and infant outcomes. Two important variables - the likelihood of requiring pharmacologic treatment for NAS (27.6% in marijuana exposed infants vs. 15.7% in non-marijuana exposed infants, p=0.066) and the duration of infant hospital stay (7.7days in marijuana exposed infants vs. 6.6days in non-exposed infants, p=0.053) trended toward significance. CONCLUSIONS: Preliminary results indicate that marijuana exposure in the third trimester does not complicate the pregnancy or the delivery process. However, the severity of the infant withdrawal syndrome in the immediate postnatal period may be impacted by marijuana exposure. Because previous study of prenatal marijuana exposure has yielded mixed results, further analysis is needed to determine whether these findings are indeed significant.

Maternal Buprenorphine Dose at Delivery and Its Relationship to Neonatal Outcomes.

BACKGROUND/AIMS: To determine whether there is a dose-response relationship between maternal dose of buprenorphine at delivery and neonatal outcomes. METHODS: This retrospective cohort study of 155 maternal-infant dyads exposed to buprenorphine during pregnancy examines the relationship between maternal dose of buprenorphine at delivery and gestational age, birthweight, method of delivery, Apgar scores at 1 and 5 min, duration of infant hospital stay, peak neonatal abstinence syndrome (NAS) score, duration of NAS and incidence of pharmacologic treatment of NAS. RESULTS: Analyses failed to support any relationship between maternal dose of buprenorphine at delivery and any of the 9 clinical outcomes (all p values >0.093). CONCLUSIONS: This study failed to provide any evidence to support limiting or reducing maternal dose of buprenorphine during pregnancy in order to reduce possible adverse outcomes to the infant. Findings suggest that healthcare providers can focus medication decisions on maternal opioid cravings to reduce the risk of relapse to illicit opioid use rather than out of concern for adverse infant outcomes.

Does concurrent in utero exposure to buprenorphine and antidepressant medications influence the course of neonatal abstinence syndrome?

OBJECTIVE: To determine whether concurrent in utero exposure to buprenorphine and antidepressants impacts the course of neonatal abstinence syndrome (NAS) in infants. METHODS: A retrospective cohort study of 148 infants who were exposed to buprenorphine during pregnancy. Univariate and bivariate analyses were used to examine associations between concurrent maternal use of buprenorphine and antidepressants as compared to maternal use of buprenorphine alone. RESULTS: The time to onset of NAS resolution was significantly longer in infants exposed to both buprenorphine and antidepressants during pregnancy when compared to those exposed to buprenorphine alone (129.8 h versus 70.2 h, p = 0.042). CONCLUSIONS: Women who are prescribed both antidepressants and buprenorphine during pregnancy should be counseled about the possibility of a prolonged course of neonatal abstinence syndrome.

Breastfeeding rates and the relationship between breastfeeding and neonatal abstinence syndrome in women maintained on buprenorphine during pregnancy.

INTRODUCTION: Although a growing body of evidence suggests that buprenorphine is a safe alternative to methadone in the treatment of opioid-dependent pregnant women, little is known about breastfeeding in this population. The first objective of this study was to describe breastfeeding rates among opioid-dependent pregnant women maintained on buprenorphine in an integrated medical and behavioral health program. The second objective was to determine whether breastfeeding is related to the duration, severity, and frequency of pharmacologic treatment for neonatal abstinence syndrome (NAS). METHODS: A retrospective chart review was conducted for all infants born to opioid-dependent pregnant women treated in the integrated buprenorphine program between December 2007 and August 2012. RESULTS: Eighty-five maternal-infant pairs were identified. Sixty-five women (76%) chose to breastfeed their infants after birth; of the women who initiated breastfeeding in the hospital, 66% were still breastfeeding 6 to 8 weeks postpartum. Although the data suggest that infants who were breastfed had less severe NAS (mean peak NAS, 8.83 vs 9.65 on a modified Finnegan Scoring System) and were less likely to require pharmacologic treatment (23.1% vs 30.0%) than infants who were not breastfed, these results were not statistically significant. DISCUSSION: More than three-quarters of the opioid-dependent pregnant women in this case series chose to breastfeed after birth. Although a direct comparison of care models is not possible, the integrated model of care potentially reduced some of the barriers to breastfeeding as the women accessed all their care in a single, infant-friendly setting. Further work is needed to definitively determine whether breastfeeding mitigates NAS.

Are there gender related differences in neonatal abstinence syndrome following exposure to buprenorphine during pregnancy?

AIM: To determine whether infant gender influences the course of neonatal abstinence syndrome (NAS) following exposure to buprenorphine during pregnancy. METHODS: A retrospective cohort study was performed in which maternal and infant data were collected for 46 male and 44 female infants. All infants were born to women enrolled in a buprenorphine treatment program from December 2007 until October 2012. Maternal and infant characteristics and outcomes were compared by infant gender. RESULTS: Male infants had a significantly higher mean peak NAS score (10.04 vs. 7.98, P=0.028) and were more likely to require pharmacologic treatment for NAS (39.1% vs. 11.4%, P=0.005). CONCLUSIONS: These data indicate that, following exposure to buprenorphine during pregnancy, male infants experience a more severe withdrawal syndrome and are more likely to require pharmacologic treatment for NAS.

Management of women treated with buprenorphine during pregnancy.

The management of pregnancy and delivery of a woman on opiate-substitution therapy with buprenorphine requires a coordinated team approach by social services, addiction medicine, obstetrics, and pediatrics. Her obstetrical care is further complicated by the unique pharmacology of buprenorphine and the issues of pain management. Obstetrical providers should be familiar with the complex issues surrounding the optimal care of these women.

Observational study of buprenorphine treatment of opioid-dependent pregnant women in a family medicine residency: reports on maternal and infant outcomes.

PURPOSE: Within a family medicine residency, an outpatient buprenorphine treatment program was provided for pregnant women who were dependent on opioids. The purpose of this study was to investigate the outcomes of infants who were exposed to a range of doses of buprenorphine in utero and to determine how closely observed maternal/fetal outcomes (eg, method of delivery and infants requiring treatment for neonatal abstinence syndrome [NAS]) match those previously reported in the literature. METHODS: This study consists of a retrospective case series of 23 infants born to 22 pregnant women who were dependent on opioids and who were treated with buprenorphine during a 31-month period. RESULTS: Thirty-five percent of infants (8 of 23) required treatment for NAS. There was no significant relationship between maternal dose of buprenorphine and birth weight, NAS severity (ie, peak NAS score), or time to first peak NAS score. Infants born to tobacco users had a significantly lower birth weight (P = .0136) than infants born to nonusers. Seventy percent of infants (16 of 23) were breastfeeding at the time of discharge from the hospital. CONCLUSIONS: The observations made in this case series are consistent with data previously reported in the literature. Infants in this study were more likely to be breastfed than those previously described by others, but further analysis is necessary to determine whether this finding is significant.

Electric power plant emissions and public health.

The generation of electric power is one important source of pollutants such as mercury, sulfur dioxide, nitrogen oxides, and fine particulate matter that can affect the respiratory, cardiovascular, and central nervous systems and cause pregnancy complications. But protecting people from environmental health hazards has become increasingly complex. Air pollutants are often invisible and travel many miles virtually undetected. Nurses can play a critical role in preventive strategies, as well as in the national debate on energy production and dependence on fossil fuels.

Modifiable risk factors for impaired fertility in women: what nurse practitioners need to know.

PURPOSE: To provide an overview of impaired fertility in childbearing-aged women, to review the current research on modifiable lifestyle risk factors implicated in its development, and to suggest strategies for nurse practitioners (NPs) to assist women in behavioral changes that will allow them to protect their fertility. DATA SOURCES: Original research articles and comprehensive review articles identified through Medline, CINAHL, and OVID databases. CONCLUSIONS: Research has shown that advancing age, a history of a sexually transmitted infection and/or pelvic inflammatory disease, extremes of body weight, and tobacco and caffeine use are potentially modifiable risk factors in the development of impaired fertility. IMPLICATIONS FOR PRACTICE: NPs must be aware of the link between these behaviors and the development of impaired fertility in order to assist women in preserving their fertility. Individual counseling, education, and community-wide education strategies are discussed.