The management of opioid dependence during pregnancy in rural and remote settings

Jumah, Naana Afua; Graves, Lisa

doi:10.1503/cmaj.131723

Cited by 13 publications

(17 citation statements)

References 39 publications

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“…Addressing this high cost and medical resource‐intensive public health issue involves a multifaceted approach to policy, interventions, and evaluation of systematic efforts. Rural pregnant women with substance use disorders have unique treatment needs; therefore, future research is needed to identify optional substance use treatment and potential barriers to treatment access for this population.…”

Section: Discussionmentioning

confidence: 99%

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Neonatal Abstinence Syndrome in West Virginia Substate Regions, 2007‐2013

Stabler

Long

Chertok

et al. 2016

The Journal of Rural Health

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Purpose The opioid epidemic is a public health threat with consequences affecting newborns. Neonatal Abstinence Syndrome (NAS) is a constellation of withdrawal symptoms resulting primarily from in utero opioid exposure. The purpose of this study is to examine NAS and drug-specific trends in West Virginia (WV), where rurality-related issues are largely present. Methods The 2007–2013 WV Health Care Authority, Uniform Billing Data were analyzed for 119,605 newborn admissions with 1,974 NAS diagnoses. NAS (ICD9-CM 779.5) and exposure diagnostic codes for opioids, hallucinogens, and cocaine were utilized as incidence rate (IR) per 1,000 live births. Findings Between 2007 and 2013, NAS IR significantly increased from 7.74 to 31.56 per 1,000 live births per year (Z: −19.10, P < .0001). During this time period, opioid exposure increased (Z: −9.56, P < .0001), while cocaine exposure decreased (Z: 3.62, P = .0003). In 2013, the southeastern region of the state had the highest NAS IR of 48.76 per 1,000 live births. NAS infants were more likely to experience other clinical conditions, longer hospital stay, and be insured by Medicaid. Conclusions Statewide NAS IR increased four-fold over the study period, with rates over 3 times the national annual averages. This alarming trend is deleterious for the health of WV mother-child dyads and it strains the state’s health care system. Therefore, WV has a unique need for prenatal public health drug treatment and prevention resources, specifically targeting the southeastern region. Further examination of maternal drug-specific trends and general underutilization of neonatal exposure ICD-9-CM codes is indicated.

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Section: Discussionmentioning

confidence: 99%

“…Substance use during pregnancy is more common among women residing in rural areas . Rural pregnant women have increased rates of prescription opiate, benzodiazepine, and injection drug use compared to pregnant women from urban areas .…”

mentioning

confidence: 99%

Neonatal Abstinence Syndrome in West Virginia Substate Regions, 2007‐2013

Stabler

Long

Chertok

et al. 2016

The Journal of Rural Health

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“…Methadone has traditionally been the standard of care for the treatment of opioid dependence in pregnancy, due to evidence for reduced illicit opioid use, high treatment retention, and no strong evidence for a risk for adverse pregnancy outcomes. The exception to this is NAS, which is characterized by problems with feeding, sleeping, and temperature regulation in the neonate .…”

Section: Methodsmentioning

confidence: 99%

“…This approach allows for maintenance of a steady opioid concentration, thus avoiding repeated episodes of intoxication and withdrawal and associated harmful fetal effects. MAT with methadone or BPN during pregnancy is associated with reduced rates of illicit opioid use, increased prenatal treatment retention, decreased pregnancy complications, and improved fetal outcomes compared with untreated opioid dependence in pregnancy . BPN should be considered for women who are already stabilized on this medication and for women who are naïve to opioid agonist therapy, but studies do not generally support a change to BPN for women who are already stabilized on methadone .…”

Section: Methodsmentioning

confidence: 99%

Medication Use and Pain Management in Pregnancy: A Critical Review

Black¹,

Khor

Kennedy

et al. 2019

Pain Practice

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Background Pain during pregnancy is common, and its management is complex. Certain analgesics may increase the risk for adverse fetal and pregnancy outcomes, while poorly managed pain can result in adverse maternal outcomes such as depression and hypertension. Guidelines to assist clinicians in assessing risks and benefits of exposure to analgesics for the mother and unborn infant are lacking, necessitating evidence‐based recommendations for managing pain in pregnancy. Methods A comprehensive literature search was conducted to assess pregnancy safety data for pharmacological and nonpharmacological pain management methods. Relevant clinical trials and observational studies were identified using multiple medical databases, and included studies were evaluated for quality and possible biases. Results Paracetamol and nonsteroidal anti‐inflammatory drugs (NSAIDs) are appropriate for mild to moderate pain, but NSAIDs should be avoided in the third trimester due to established risks. Short courses of weaker opioids are generally safe in pregnancy, although neonatal abstinence syndrome must be monitored following third trimester exposure. Limited safety data for pregabalin and gabapentin indicate that these are unlikely to be major teratogens, and tricyclic antidepressants and serotonin‐norepinephrine reuptake inhibitors have limited but overall reassuring safety data. Many of the included studies were limited by methodological issues. Conclusions Findings from this review can guide clinicians in their decision to prescribe analgesics for pregnant women. Treatment should be tailored to the lowest therapeutic dose and shortest possible duration, and management should involve a discussion of risks and benefits and monitoring for response. Further research is required to better understand the safety profile of various analgesics in pregnancy.

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“…Owing to these factors, it is being used widely in opioid treatment programmes in rural and remote settings where methadone treatment is not available 23. Currently women participating in buprenorphine+naloxone treatment programmes who become pregnant are advised to switch to the buprenorphine mono-product out of theoretical concerns of the risk of naloxone to the developing fetus.…”

Section: Discussionmentioning

confidence: 99%

Observational study of the safety of buprenorphine+naloxone in pregnancy in a rural and remote population

et al. 2016

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ObjectivesTo describe the effect of in utero exposure to the buprenorphine+naloxone combination product in a rural and remote population.SettingA district hospital that services rural and remote, fly-in communities in Northwestern Ontario, Canada.ParticipantsA retrospective cohort study was conducted of 855 mother infant dyads between 1 July 2013 and 30 June 2015. Cases included all women who had exposure to buprenorphine+naloxone during pregnancy (n=62). 2 control groups were identified; the first included women with no opioid exposure in pregnancy (n=618) and the second included women with opioid exposure other than buprenorphine+naloxone (n=159). Women were excluded if they had multiple pregnancy or if they were part of a methadone programme (n=16). The majority of women came from Indigenous communities.OutcomesThe primary outcomes were birth weight, preterm delivery, congenital anomalies and stillbirth. Secondary neonatal outcomes included gestational age at delivery, Apgar scores at 1 and 5 min, NAS Score >7 and treatment for neonatal abstinence syndrome (NAS). Secondary maternal outcomes included the number of caesarean sections, postpartum haemorrhages, out of hospital deliveries and transfer of care to tertiary centres.ResultsNo difference was found in the primary outcomes or in the Apgar score and caesarean section rate between in utero buprenorphine+naloxone exposure versus no opioid exposure in pregnancy. Compared to women taking other opioids, women taking buprenorphine+naloxone had higher birthweight babies (p=0.001) and less exposure to marijuana (p<0.001) during pregnancy.ConclusionsRetrospective data suggest that there likely is no harm from taking buprenorphine+naloxone opioid agonist treatment in pregnancy. Larger, prospective studies are needed to further assess safety.

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The management of opioid dependence during pregnancy in rural and remote settings

Cited by 13 publications

References 39 publications

Neonatal Abstinence Syndrome in West Virginia Substate Regions, 2007‐2013

Neonatal Abstinence Syndrome in West Virginia Substate Regions, 2007‐2013

Medication Use and Pain Management in Pregnancy: A Critical Review

Observational study of the safety of buprenorphine+naloxone in pregnancy in a rural and remote population

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