First Trimester Use of Buprenorphine or Methadone and the Risk of Congenital Malformations

Suarez, Elizabeth A.; Bateman, Brian T.; Straub, Loreen; Hernández-Díaz, Sonia; Jones, Hendrée E.; Gray, Kathryn J.; Connery, Hilary S.; Davis, Jonathan M.; Lester, Barry; Terplan, Mishka; Zhu, Yanmin; Vine, Seanna M.; Mogun, Helen; Huybrechts, Krista F.

doi:10.1001/jamainternmed.2023.6986

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JAMA Intern Med

2024

DOI: 10.1001/jamainternmed.2023.6986

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First Trimester Use of Buprenorphine or Methadone and the Risk of Congenital Malformations

Elizabeth A. Suarez,

Brian T. Bateman,

Loreen Straub

et al.

Abstract: ImportanceUse of buprenorphine or methadone to treat opioid use disorder is recommended in pregnancy; however, their teratogenic potential is largely unknown.ObjectiveTo compare the risk of congenital malformations following in utero exposure to buprenorphine vs methadone.Design, Setting, and ParticipantsThis population-based cohort study used health care utilization data from publicly insured Medicaid beneficiaries in the US from 2000 to 2018. A total of 13 360 pregnancies with enrollment from 90 days prior t… Show more

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Cited by 6 publications

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“…In the Original Investigation titled “First Trimester Use of Buprenorphine or Methadone and the Risk of Congenital Malformations,” published in the March 2024 issue of JAMA Internal Medicine , there was an error in Figure 1. A total of 9734 patients, rather than 7934 patients, were exposed to buprenorphine in the first trimester.…”

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confidence: 86%

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2024

JAMA Intern Med

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confidence: 86%

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2024

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Prenatal Opioid Use Disorder Treatment—the Importance of Shared Decision-Making

Nguemeni Tiako,

Knight,

Schiff

2024

JAMA Intern Med

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In this issue of JAMA Internal Medicine, Suarez et al 1 studied a population-based cohort of publicly insured pregnant individuals receiving methadone or buprenorphine for opioid use disorder (OUD) in the US. Their study adds considerably to the sparse literature on rates of congenital malformations among newborns with in utero exposure to buprenorphine and methadone. The authors found a 1% absolute risk reduction of congenital malformations from buprenorphine exposure compared with methadone. First-trimester exposure to methadone was associated with higher odds of cardiac malformations, oral clefts, and clubfoot than buprenorphine. In secondary analyses, they found that buprenorphine exposure was associated with higher odds of gastrointestinal-specific malformation, mostly pyloric stenosis.The authors use robust statistical methods to address residual confounding concerns, including propensity score matching to account for a greater percentage of the methadoneexposed cohort being a race or ethnicity other than White, living in urban areas, and having lower county-level socioeconomic status. 1 They conducted multiple sensitivity analyses, including using individuals who underwent secondtrimester initiation of medications for opioid use disorder (MOUD) as a negative control group under the conventional assumption that most teratogenicity can be attributed to firsttrimester exposures.Despite the cutting-edge statistical analyses, unmeasured environmental confounders may play a role in explaining the study findings. 1 However, additional research is needed to better understand potential mechanisms causing different effects of methadone and buprenorphine on organogenesis and congenital malformations. Prior work by Suarez's research group evaluating exposure to prescribed opioids using the same data source did not find a substantial increase in anomalies following first-trimester exposure to full μ-opioid receptor agonists. 2 Comparing the current study cohort with one of unexposed pregnancies would aid in the interpretation of the findings specific to methadone (a full μ-opioid receptor agonist) and buprenorphine (a partial μ-opioid receptor agonist). Similarly, the authors' new finding of an association between buprenorphine and pyloric stenosis is important. 1 However, it requires further investigation because pyloric stenosis is less clearly linked to first-trimester exposures than cardiac and neural tube anomalies.For clinicians treating patients who are newly pregnant or contemplating pregnancy, it is essential to place the study's findings in the context of the current phase of the opioid overdose epidemic. First, the pregnant individuals included in this study comprise a relatively stable group of patients with OUD-Invited Commentary and Editor's Note

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Medication for the Treatment of Opioid Use Disorder in Pregnancy Is Essential

Poland,

Stoltman,

Felton

2024

JAMA Intern Med

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National practice groups and decades of research strongly support treating opioid use disorder (OUD) as a chronic illness and specifically call for the use of evidence-based medications to treat OUD throughout pregnancy and beyond. The criterionstandard medications for OUD (MOUD), including during pregnancy, are buprenorphine (approved by the US Food and Drug Administration in 2002) and methadone (approved by the US Food and Drug Administration to treat OUD in 1972). 1 While evidence suggests that pregnancy may represent a specific window of opportunity to engage individuals in MOUD and that MOUD leads to better outcomes for the maternal-infant dyad, 2 fewer than 1 in 4 individuals with OUD receive treatment in any given month of pregnancy. 3 Improperly treated OUD (eg, not using MOUD or abruptly stopping opioids during pregnancy) has substantial negative effects, increasing morbidity and mortality for the maternalinfant dyad. Research clearly demonstrates that untreated OUD during pregnancy is associated with a number of detrimental effects on the health of the infant (including structural abnormalities and fetal death) and mother (including overdose and maternal death). 2 Despite overwhelming support for the use of MOUD in pregnancy, 1 there are numerous barriers to engaging people in appropriate care, including stigma among prescribing physicians, inadequate training and resources for clinicians, and patient concerns. The primary concerns expressed by patients related to MOUD in pregnancy include the risk of state intervention (eg, loss of custody, criminal proceedings) and perceived negative implications of medication for the infant, including neonatal abstinence syndrome/neonatal opioid withdrawal syndrome (NAS/NOWS). 4 These issues lead to delayed care or avoidance of appropriate treatment and also contribute to negative outcomes for the maternal-infant dyad. Importantly, there are a number of clinical and legal interventions that have the potential to address these barriers and concerns. These include family-centered, evidence-based approaches to treating NAS/NOWS, like Eat, Sleep, Console, 5 and evolving policies that reduce harms toward historically marginalized populations who have been disproportionately affected by reporting based only on positive drug screens. Mandated state reporting of positive drug screens in pregnant people results in ongoing and harmful family control measures that also affect continuing on MOUD or seeking care. Indeed, many of these institutions (eg, departments of child services or child protective services) encourage people to use nonpharmacological management of their OUD and often place contingencies on patients without consultation with health care teams. Health care professionals working with pregnant and postpartum patients who use opioids must understand the Invited Commentary and Editor's Note

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First Trimester Use of Buprenorphine or Methadone and the Risk of Congenital Malformations

Cited by 6 publications

References 39 publications

Error in Figure 1

Error in Figure 1

Prenatal Opioid Use Disorder Treatment—the Importance of Shared Decision-Making

Medication for the Treatment of Opioid Use Disorder in Pregnancy Is Essential

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