No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Comparison of adverse obstetric outcomes and maternity hospitalization among heroin-exposed and methadone-treated women in Taiwan
... Existing evidence concerning health issues of this vulnerable population focuses mostly on those born to women who use opioids during pregnancy. Fetal opioid exposure has been linked to great risks of unfavorable outcomes at birth, including stillbirth, low birth weight, and preterm birth ( Chen et al., 2015;Hulse et al., 1998;Jansson and Velez, 2011). Notably, such risks may remain through or even worsen in the first year of life, with manifestations in both health and developmental problems ( Ornoy et al., 1996;Ross et al., 2015). ...
... The underlying pathways connecting parental opioid use and adverse outcomes in offspring have been the focus of considerable research across clinical practice and social services ( Buckley et al., 2013;Hulse et al., 1997;Jansson and Velez, 2011;Kelly et al., 2012;Nair et al., 2003), among which the drug-exposure and the social-contextual perspectives are two of the most cited explanations. The drug-exposure perspective attributes the health and developmental problems of children to the harmful effects of drug exposure, mostly through the placenta ( Burns et al., 2010;Chen et al., 2015;Hulse et al., 1997;Jansson and Velez, 2011;Kelly et al., 2012). In the case of heroin, medication treatment (e.g., methadone) for pregnant women has been shown to be beneficial with early and continuous engagement, with antenatal care as a vital contributory mechanism ( Buckley et al., 2013). ...
... Methadone is dispensed only through oral formulation, daily clinic visits are mandatory, and take-home doses are not allowed. Because the MMT data after the year 2009 were not released for research purposes, the present study is based primarily on the 2006-2009 MMT dataset ( Chen et al., 2015;Fang et al., 2015). During this study period, methadone was the only medication used for heroin treatment in Taiwan. ...
Background:
Young offspring of individuals with opioid use disorders have great exposure to a wide array of social disadvantages and stressors. This study aimed to investigate excess mortality before the age of six and predictors of premature death in children born to opioid-involved parents.
Methods:
A total of 3210 children born between 2004 and 2009 to parents with opioid use disorders (roughly a quarter of whom were born after parental methadone treatment enrollment) were identified in Taiwan. Information concerning sociodemographic characteristics, history of medical condition, and survival status was obtained through data linkage with the National Health Insurance Database and death registration. The age-, birth year-, and sex-adjusted standardized mortality ratios (SMRs) and survival analyses were used to assess risk estimates and evaluate predictors.
Results:
The overall SMR for children with opioid-involved parents was 2.31 (95% confidence interval [CI] = 1.68-3.10), with the estimate reaching 4.23 (95% CI = 2.37-6.97) when the causes of death were unnatural (e.g., injury and accident). The most salient predictors of premature death were low birth weight and paternal opioid problem severity, which increased risk of premature death 2.5--5.2-fold (all P < 0.05). Being born after parents enrolled in methadone treatment was slightly associated with a reduced risk of death in those mothered by opioid users (adjusted hazard ratio = 0.30).
Conclusion:
The elevated risk of premature death in the offspring of opioid-addicted parents suggests the need to prioritize resource allocation to safeguard this marginalized and vulnerable segment of the pediatric population.
... Cumulative evidence suggests that methadone is beneficial to heroin-dependent pregnant women in terms of pregnancy outcomes; however, there is still a great concern about the adverse effects of methadone on neonates' health outcomes (Hulse et al., 1998a, b;Kennare et al., 2005;Webster et al., 1996). Some clinical observational studies have found that certain unfavorable neonatal outcomes, such as growth retardation, low birth weight, preterm delivery, and neonatal abstinence syndrome [NAS], were very common (e.g., NAS: 40-75%) among the offspring of women enrolled in the opioid substitute therapy (Burns et al., 2010;Chen et al., 2015;Cleary et al., 2012;Dryden et al., 2009;Hulse et al., 1997Hulse et al., , 1998bKakko et al., 2008). Relative to infants of non-drug using mothers, the needs in healthcare for children born to women on an opioid substitute therapy are expected to be higher (Johnson et al., 2003;Jones et al., 2010;Kakko et al., 2008), and as such their access to quality and regular well child services is especially important. ...
... Through this procedure, an estimated 88% of the 1 039 569 live births in the Birth Notification System were linked with the Birth Registry during the years 2004-2008. Important children's and maternal characteristics were retrieved from the Birth Notification System (e.g., preterm delivery and age at delivery) and the Birth Registry (e.g., maternal marital status; Chen et al., 2015). ...
... In this study on accessibility and utilization of healthcare during the first year of life, we defined children who were born between 2004 and 2008 and have lived to the first birthday as the study population. According to the initial enrollment date in the MMT and the date of delivery, infants born to mothers in the MMT were subdivided into two groups: those born before the enrollment (BM: n = 857; the average interval between delivery and MMT enrollment is 2.4 years) and after (AM: n = 199; the third quartile compliance rate through pregnancy was estimated 60%) (see Fig. 1 for data linkage process; Chen et al., 2015). In this study, the children in the BM group are assumed to be heroin-exposed since empirical evidence indicated that average year of heroin history prior to MMT was 5 years in Taiwan (Lin et al., 2013). ...
... The Methadone Maintenance Treatment (MMT) program was initially implemented in 2006 to control the increasing number of human immunodeficiency virus (HIV) infections associated with injecting drug users in Taiwan. Methadone can be taken only through oral formulation, and patients with heroin use disorders must visit clinics on a daily basis (Chen et al., 2015). The intake evaluation for methadone treatment involved addiction assessment and focused physical examination (e.g., HIV and hepatitis). ...
... As to health condition prior to treatment initiation, our analyses did not detect the significant contribution of alcohol use disorder or prior attempted suicides to the risk of suicide in the women seeking methadone treatment; however, a slightly elevated risk pointed out the importance of methadone-intake assessment. A concerning yet expected finding was that having a prior history of depressive disorder may increase two-to three-fold risk of suicide attempts and suicide death (Chen et al., 2015;Darke and Ross, 2002;Pan et al., 2014;Yuodelis-Flores and Ries, 2015). Our observation highlights the role of depressive disorders in shaping the risk of suicide in the course of addiction recovery, reinforces the need to continuously assess co-occurring psychiatric disorders, and emphasizes the importance of integrating addiction and social services, which is especially urgent for women with substance use disorder -a clinically high-risk group for suicide ideation and behaviors (Oquendo and Volkow, 2018;Schulze and Krätschmer-Hahn, 2014;Tuchman, 2010;Yuodelis-Flores and Ries, 2015). ...
Background:
The present study aims to profile the hazard fluctuation of suicide attempts and deaths among heroin-involved women seeking methadone maintenance treatment (MMT) and to investigate sociodemographic and clinical factors predicting the time to have suicidal behaviors.
Methods:
We identified a retrospective cohort comprising 2780 women receiving methadone treatment in the period of 2012-2016. Healthcare records were obtained from Taiwan's National Health Insurance Research Database, and suicide deaths were ascertained from the national death register. Competing risk survival analyses were used to estimate the risk of suicide attempts and deaths within one year and three years of MMT enrollment.
Results:
A total of 1.2 % of MMT-treated women ever visited hospital for suicide attempt, and 0.5 % died by confirmed suicide. The risk of treated suicide attempt reached its peak at the end of the 8th month after methadone initiation, whereas the risk of confirmed suicide death was relatively stable during the first one and a half years. A history of treated depressive disorders appears to be the strongest risk predictor for treated suicide attempts (Adjusted Hazard Ratio [aHR] = 3.45; 95 % CI = 1.66-7.19) and confirmed suicide death (aHR = 3.47; 95 % CI = 1.20-10.0). Retaining in methadone treatment may significantly lower the hazard of probable suicide death by 52 %.
Conclusions:
Women with heroin use disorders should receive careful attention for suicide risk at intake assessment and over the course of treatment and recovery. Preventive strategies should target unmet clinical and social needs and evaluate gender-specific barriers for treatment engagement.
... How women in subpopulations characterized by socially disadvantaged backgrounds and high-risk conditions utilize prenatal care is of critical concern to medical communities (Hollowell, Kurinczuk, Oakley, Brocklehurst, & Gray, 2009;Kershaw et al., 2009;Lia-Hoagberg et al., 1990;Vintzileos et al., 2002). Women using substance, a highrisk subgroup at elevated risks of delivery complications and adverse birth outcomes (Burns, Mattick, & Cooke, 2006;Chen, Lien, Yeh, Su, & Ho, 2015;Lester et al., 2002), are disproportionately represented in prenatal care clients (Funkhouser, Butz, Feng, McCaul, & Rosenstein, 1993;Jessup, Humphreys, Brindis, & Lee, 2003;Roberts & Pies, 2011;Schempf & Strobino, 2009). Earlier studies on pregnant women in inner cities areas of the U.S. reported that frequent substance users were 2.5 times more likely to have low utilization of prenatal care (Funkhouser et al., 1993). ...
... In the background of the rising number of women with opioid use disorders in many parts of the world (Brogly et al., 2017;Chen et al., 2015;Martins et al., 2017), the present study first examined the association linking methadone treatment with the number of prenatal visits among pregnancies by women with opioid use disorders. Next, with a focus on those pregnancies with methadone treatment, we further investigated treatment characteristics associated with utilization of prenatal care and early entry into prenatal services. ...
Aims
The present study aims to investigate the utilization pattern of prenatal care and correlates for women with opioid use disorders (OUD) in Taiwan.
Method
Using the data linkage between the Methadone Maintenance Treatment (MMT) register with national health insurance, national birth notification system, and birth registration system, we identified 1712 pregnancies with 20 or more gestational weeks from women enrolled in the MMT (heroin-exposed: receiving no methadone treatment during pregnancy, n = 1053 by 882 women; methadone-treated: receiving methadone for at least one day during pregnancy, n = 659 by 574 women) and their 1:10 matched pregnancies from 17,060 women without substance use disorder in the period of 2004-2013. The generalized linear mixed models with negative binomial and logit distributions were performed to evaluate the relationship between individual sociodemographic, health, and addiction treatment characteristics with the number of prenatal visits and receiving prenatal care in the first trimester (i.e., early entry).
Findings
Eighteen percent of pregnancies by women with OUD received no prenatal services and 21% had started prenatal care in the first trimester as compared with 1% and 46% in pregnancies by women without substance use disorders. For pregnancies by women with OUD, methadone treatment was not linked associated with prenatal care visits (adjusted relative risk [aRR] = 1.02; 95% = 0.92, 1.12). For methadone-treated pregnancies, treatment enrollment before pregnancy and spousal methadone treatment elevated prenatal visits by 8% and 18% (0.48 and 1.08 visits, respectively). Additionally, HIV infection (adjusted odds ratio [aOR] = 0.30, 95% CI = 0.10, 0.83) and prior delivery (aOR = 0.05, 95% CI = 0.01, 0.19) significantly reduced the odds of early entry into prenatal care.
Conclusion
Integrating addiction treatment programs with prenatal care is urgently needed to increase adequate prenatal care for pregnant women with OUD, especially the multiparous ones.
... Cumulative evidence suggests that methadone is beneficial to heroin-dependent pregnant women in terms of pregnancy outcomes ; however, there is still a great concern about the adverse effects of methadone on neonates' health outcomes (Hulse et al., 1998a, b; Kennare et al., 2005; Webster et al., 1996). Some clinical observational studies have found that certain unfavorable neonatal outcomes, such as growth retardation, low birth weight, preterm delivery, and neonatal abstinence syndrome [NAS] , were very common (e.g., NAS: 40–75%) among the offspring of women enrolled in the opioid substitute therapy (Burns et al., 2010; Chen et al., 2015; Cleary et al., 2012; Dryden et al., 2009; Hulse et al., 1997 Hulse et al., , 1998b Kakko et al., 2008). Relative to infants of non-drug using mothers, the needs in healthcare for children born to women on an opioid substitute therapy are expected to be higher (Johnson et al., 2003; Jones et al., 2010; Kakko et al., 2008), and as such their access to quality and regular well child services is especially important. ...
... In this study on accessibility and utilization of healthcare during the first year of life, we defined children who were born between 2004 and 2008 and have lived to the first birthday as the study population. According to the initial enrollment date in the MMT and the date of delivery, infants born to mothers in the MMT were subdivided into two groups: those born before the enrollment (BM: n = 857; the average interval between delivery and MMT enrollment is 2.4 years) and after (AM: n = 199; the third quartile compliance rate through pregnancy was estimated 60%) (see Fig. 1for data linkage process; Chen et al., 2015). In this study, the children in the BM group are assumed to be heroin-exposed since empirical evidence indicated that average year of heroin history prior to MMT was 5 years in Taiwan (Lin et al., 2013). ...
Objective: This study investigated the insurance coverage for offspring of mothers in the Methadone Maintenance Treatment (MMT) and examined the relationships between infant's preventive service and curative care utilization with maternal illegal drug treatment history.
Methods: Data were obtained from the national MMT database, the National Birth Notification and Registration Databases, and the National Health Insurance Research Database. Through data linkage, we identified 199 infants with mothers in the MMT, and 1:10 controls matching on birth year (2006-2008), maternal age, and socioeconomic status (primarily lower SES); 258 were identified as the other control group when their non-MMT enrolled mothers had illegal drug problems visits (ICD-9CM code: 304, 305) within the year prior to delivery. Logistic and two-part regression models were employed to evaluate the association estimates.
Results: Even when national health insurance is enforced, only 54% of children with mothers in the MMT received continued insurance coverage in the first year of life. With potential confounders adjusted, infants with MMT enrolled mothers were at 1.4-fold risk to have no/discontinued health insurance (P < 0.01) as compared to those with matched mothers; the visits for well-baby preventive service and curative healthcares were significantly lowered (β=-0.45 and -0.01). Relationship estimates were slightly greater when in comparison with those born to drug-using control (adjusted Odds Ratio=2.3; β=-0.40, -0.83, Ps<.001).
Conclusion: Harm reduction programs for women with child-bearing ages should be delivered in coordinated care systems that ensure the comprehensiveness and continuum in healthcare, child welfare, and social service.
... Dykeman and Williams 25 and Bacate et al 26 examined the national health insurance plans and maternity benefits in Canada and the Philippines respec- tively and concluded that cost of training of obstetrics and gynecology that are surcharged on the maternity insur- ance fund must be excluded from the expenditure of the fund. In other studies, Moudi et al, 27 Hennegan et al, 28 Gorman et al, 29 and Chen et al 30 respectively introduced the experience of obstetric care in Iran, Queensland, the United States, Poland, Scotland, and Taiwan. These studies established the need to reduce the cost of childbirth in order to promote fairness and recognize ethnic differences of vulnerable groups. ...
This study aims to examine the impact of China's population policy changes on social insurance. Nearly 4 decades ago, China ushered in the 1‐child policy as a family planning policy to control the adverse effect of high population growth. The current maternity insurance system in China is designed to fit the operations of the 1‐child policy. However, the implementation of the comprehensive 2‐child policy can pose a challenge to the sustainability of the current maternity insurance scheme hence the call for reform.
The study empanels a novel and comprehensive system dynamic model that incorporates all the related factors that influence the income and expenditure of maternity insurance in the Jiangsu Province. Data are mainly derived from the historical data of the Statistical Yearbook of Jiangsu Province and the National Bureau of Statistics of China. These are used to construct and simulate a system dynamic model to determine a sustainable contribution rate for maternity insurance.
In conclusion, if the rate of contribution of the current maternity insurance policy is not increased, the burden of implementing the comprehensive 2‐child policy will exacerbate the current deficit balance of the maternity insurance fund. The existing maternity insurance benefits thus cannot be maintained, and women's health will be threatened. In the short term, the study proposes an increase in the rate of premium payment to prolong the life of the maternity insurance. In the long term, there is a need to improve the level of coordination and expand the coverage of maternity insurance.
Objective
To assess the cost effectiveness of buprenorphine versus methadone in the management of opioid use disorder (OUD) during pregnancy.
Methods
We designed a decision-analytic model to evaluate the costs and outcomes associated with buprenorphine compared to methadone for pregnant people with OUD. We used a theoretical cohort of 22,400 pregnant people, which is an estimation of pregnancies affected by OUD per year in the United States. Outcomes included maternal retention in maintenance treatment, neonatal opioid withdrawal syndrome, preterm birth, fetal growth restriction, cerebral palsy, and maternal overdose in addition to cost and quality-adjusted life-years (QALYs). We used a willingness-to-pay threshold of $100,000/QALY. All model inputs were derived from the literature and varied in sensitivity analyses to assess the robustness of our baseline inputs.
Results
In our theoretical cohort, treatment of OUD with buprenorphine during pregnancy resulted in 2413 fewer cases of neonatal opioid withdrawal syndrome, 1089 fewer preterm births, 299 fewer cases of fetal growth restriction, 32 fewer stillbirths, and 13 fewer cases of cerebral palsy compared to methadone treatment. Despite lower rates of retention, buprenorphine treatment saved nearly 123 million healthcare dollars and resulted in 558 additional QALYs, making it the dominant strategy compared to methadone treatment. Our findings were robust over a wide range of assumptions.
Conclusion
Our data suggest that buprenorphine should be considered a cost effective treatment option for OUD in pregnancy, as it is associated with improved neonatal outcomes compared to methadone despite the risk of treatment discontinuation.
Der Konsum legaler oder illegaler Substanzen kann zu Schäden der Mutter-Plazenta-Kind-Einheit führen. Am bekanntesten ist das fetale Alkoholsyndrom, es spiegelt die Teratogenität von Alkohol wider. Auch für andere Substanzen wie Nikotin, Amphetamine, Kokain und Cannabis wurden in Studien nicht nur unmittelbar postnatal Auffälligkeiten des Neugeborenen beschrieben. Vermutlich kommt es durch fetale Programmierung und Störung des neuroendokrinen Systems pränatal zu Auffälligkeiten, die bis ins Jugendalter nachweisbar sind. Für die Betreuung der substanzabhängigen Schwangeren und deren Kindern ist eine interinstitutionelle Vernetzung zwischen medizinischen Fachgebieten und Ämtern nötig.
Unlabelled:
Methadone maintenance treatment (MMT) is the standard of care during pregnancy for opioid-dependency, showing efficacy in improving prenatal care and reducing risk of relapse. By design, however, MMT is only intended to prevent withdrawal thus facilitating cognitive behavioural interventions. In order to maximize the benefits of MMT, it is essential that methadone is both properly prescribed and that additional addiction treatment is concurrently administered. This study aims to determine the effectiveness of MMT engagement in high-risk pregnant women in reducing polydrug use by objective laboratory examination of neonatal meconium.
Patients and methods:
Over a 29-month period, the Motherisk Laboratory at the Hospital for Sick Children in Toronto analyzed meconium samples as per request by social services and hospitals for drugs of abuse.
Results:
Of the 904 meconium samples received, 273 were tested for methadone with 164 positive and 109 negative for methadone. Almost half of the methadone positive samples (46.34%) were also positive for at least one other opioid compound, which did not differ statistically from the methadone-negative control samples (46.79%; Chi square test, p=0.94). No differences were found between the methadone positive and negative groups in rates of concurrent amphetamines, cocaine, cannabis, and alcohol use indicating a similar risk of polydrug use between pregnant women taking or not taking methadone in this population.
Discussion:
The high rates of additional opioid and other drug use in the MMT group, suggest that MMT is failing this population of patients. It is possible that methadone doses during pregnancy are not appropriately adjusted for changes in pharmacokinetic parameters (e.g. blood volume, renal function) during the second and third trimesters. This may result in sub-therapeutic dosing creating withdrawal symptoms leading to additional substance use. Alternatively, these results may be demonstrating a substantial lack in delivery of addiction support services in this vulnerable population.
To examine the relationship of anxiety and depression symptoms with treatment outcomes (treatment discontinuation, rates of ongoing use of illicit drugs and likelihood of preterm delivery) in opioid-dependent pregnant women and describe their use of psychotropic medications.
Secondary data analysis from a randomized clinical trial of treatment for opioid dependence during pregnancy.
A total of 175 opioid-dependent pregnant women, of whom 131 completed treatment.
Symptoms of anxiety and depression were captured with the 15-item Mini International Neuropsychiatric Interview (MINI) screen. Use of illicit drugs was measured by urine drug screening. Preterm delivery was defined as delivery prior to 37 weeks' gestation. Self-reported use of concomitant psychotropic medication at any point during the study was recorded.
Women reporting only anxiety symptoms at study entry were more likely to discontinue treatment [adjusted odds ratio (OR) = 4.56, 95% confidence interval (CI): 1.91-13.26, P = 0.012], while those reporting only depression symptoms were less likely to discontinue treatment (adjusted OR = 0.14, 95% CI: 0.20-0.88, P = 0.036) compared to women who reported neither depression nor anxiety symptoms. No statistically significant between-group differences were observed for ongoing illicit drug use or preterm delivery. A majority (61.4%) of women reported use of concomitant psychotropic medication at some point during study participation.
Opioid agonist-treated pregnant patients with co-occurring symptoms of anxiety require additional clinical resources to prevent premature discontinuation.
To characterize infections and compare obstetric outcomes in opioid-dependent pregnant women who participated in a randomized clinical trial comparing agonist medications, methadone and buprenorphine.
Incidence of infections was identified as part of the screening medical assessment. As part of a planned secondary analysis, analysis of variance and polytomous logistic regressions were conducted on obstetric outcome variables using treatment randomization condition (maternal maintenance with either methadone or buprenorphine) as the predictor variable, controlling for differences between study sites.
Six United States sites and one European site that provided comprehensive treatment to opioid-dependent pregnant women.
Pregnant opioid-dependent women (n = 131) who delivered while participating in the Maternal Opioid Treatment: Human Experimental Research (MOTHER) study.
Obstetric, infectious and other maternal medical complications captured by medical records, physical examination, blood tests and self-report. Neonatal medical complications captured by medical records.
Hepatitis C was the most common infection (32.3%), followed by hepatitis B (7.6%) and chlamydia (6.1%) among participants at study enrollment. Maternal methadone versus buprenorphine maintenance was associated with a higher incidence of preterm labor (P = 0.04) and a significantly higher percentage of signs of respiratory distress in neonates at delivery (P = 0.05). Other medical and obstetric complications were infrequent in the total sample, as well as in both methadone and buprenorphine conditions.
Buprenorphine appears to have an acceptable safety profile for use during pregnancy.
Multi-center trials enable the recruitment of larger study samples, although results might be influenced by site-specific factors.
Site differences of a multi-center prospective double-blind, double-dummy randomized controlled trial (7 centers: Central Europe (Vienna)/USA (3 urban/3 rural centers)) comparing safety and efficacy of methadone and buprenorphine in pregnant opioid-dependent women and their neonates.
Urban US women had the highest rate of concomitant opioid (p = 0.050) and cocaine consumption (p = 0.003), the highest dropout rate (p = 0.001), and received the lowest voucher sums (p = 0.001). Viennese neonates had significantly higher Apgar scores 1 min (p = 0.001) and 5 min after birth (p < 0.001) and were more often born by cesarean section (p = 0.024). Rural US newborns had a significantly shorter neonatal abstinence syndrome treatment duration compared to Viennese and urban US sites (p = 0.006), in addition to other site-specific differences, suggesting a more severely affected group of women in the urban US sites.
This clinical trial represents a role model for pharmacological treatment in this unique sample of pregnant women and demonstrates the clinical importance of considering site-specific factors in research and clinical practice.
Unlabelled:
AIMS/DESIGN: Reduction in mean birth weight and increased incidence of low birth weight are both associated with exposure to illicit heroin in pregnancy. Many studies examining neonatal outcomes in pregnant heroin users treated with methadone report improvements in birth weight. As a consequence, methadone treatment has become the 'gold standard' for the management of the pregnant heroin user. However, not all studies report significant birth weight increases associated with methadone. We undertook a number of meta-analyses on reduction in mean birth weight and incidence of low birth weight to estimate more precisely the effect of illicit heroin and methadone.
Findings:
Results showed mean reduction in birth weight associated with heroin use: 489 g (95% CI 284-693 g), compared with methadone: 279 g (229-328 g). Similarly, the pooled relative risk estimate for low birth weight for maternal heroin use was 4.61 (95% CI 2.78-7.65), compared with 1.36 (0.83-2.22) for methadone. Analysis of data on combined heroin and methadone use produced a pooled mean reduction in birth weight of 557 g (403-710 g), with a pooled relative risk estimate for low birth weight of 3.28 (2.47-4.39). Pooling 'any' methadone data, regardless of heroin use, produced an estimated reduction in birth weight of 395 g (311-478 g) and a relative risk estimate for low birth weight of 1.90 (1.29-2.81). Combining all data in an 'any' opiate use analysis also produced a mean reduction in birth weight of 483 g (386-583 g) and a relative risk estimate for low birth weight of 3.81 (2.57-5.65).
Conclusions:
The current findings suggest that heroin use while receiving methadone may counteract the birth weight advantage gained from methadone alone. Whether this is due to fetal exposure to heroin plus methadone, to reduced antenatal care, other behavioural and environmental factors associated with concurrent use of heroin and methadone or a combination of these is unclear. Nevertheless, these results challenge the current belief that the pregnant user is always better off receiving methadone than not, and suggests that methadone may not be the appropriate treatment for the pregnant women who continue to use illicit heroin.
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.
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.
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).
The differences between North American and European groups may offer unique insights concerning treatment and pregnancy outcomes for opioid-dependent pregnant women.
Abstract Background Linking population health data to pathology data is a new approach for the evaluation of predictive tests that is potentially more efficient, feasible and efficacious than current methods. Studies evaluating the use of first trimester maternal serum levels as predictors of complications in pregnancy have mostly relied on resource intensive methods such as prospective data collection or retrospective chart review. The aim of this pilot study is to demonstrate that record-linkage between a pathology database and routinely collected population health data sets provides follow-up on patient outcomes that is as effective as more traditional and resource-intensive methods. As a specific example, we evaluate maternal serum levels of PAPP-A and free β-hCG as predictors of adverse pregnancy outcomes, and compare our results with those of prospective studies. Methods Maternal serum levels of PAPP-A and free β-hCG for 1882 women randomly selected from a pathology database in New South Wales (NSW) were linked to routinely collected birth and hospital databases. Crude relative risks were calculated to investigate the association between low levels (multiples of the median ≤ 5th percentile) of PAPP-A or free β-hCG and the outcomes of preterm delivery (
Parental drug use is a critical public health issue; it is estimated to be present in up to 80% of referrals to Australian child protection agencies. However, no data regarding the child protection outcomes of infants of substance-using parents exist in Australia, and no comparisons have been made with infants of non-substance-using parents. We assessed differences in substantiated abuse between 2 groups of mothers in Brisbane to quantify this risk.
Mothers who disclosed opiate, amphetamine, or methadone use between 2000 and 2003 were identified and compared with non-substance-using mothers who were matched for gender and gestational age. All infants were linked to the Department of Child Safety Child Protection Information System database. Child protection outcomes, such as substantiated notifications and entry into foster care, were compared between groups.
We studied 119 infants of substance-using mothers and 238 matched infants. Infants of substance-using mothers were more likely to suffer substantiated harm (hazard ratio 13.3 [95% confidence interval 4.6-38.3]) and to enter foster care (hazard ratio 13.3 [95% confidence interval 5.1-34.3]). Infants of mothers using illicit drugs were more likely to suffer substantiated harm and more likely to enter foster care than infants of mothers who were compliant with a methadone program.
Infants of substance-using mothers have much poorer child protection outcomes than infants of non-substance-using mothers. This study adds substantial evidence toward a real association between maternal drug use and child abuse. Greater interagency collaboration is urgently required to reduce this risk.
Opioid maintenance treatment (OMT) is widely used to treat pregnant women with a history of opioid dependence. This study investigated whether maternal methadone/buprenorphine dose and nicotine use in pregnancy affects the occurrence and duration of neonatal abstinence syndrome (NAS) in the infant.
Forty-one pregnant women from OMT programmes in Norway who gave birth between January 2005 and January 2007 were enrolled in a national prospective study. Thirty-eight women (81% of the population) were interviewed in the last trimester of pregnancy and 3 months after delivery. Data from the European Addiction Severity Index and a questionnaire measuring enrolled birth information were compared with medical records and urine analyses.
Treatment requiring NAS occurred in 58% of the methadone-exposed and in 67% of the buprenorphine-exposed infants. There was no significant relationship between a maternal dose of methadone or buprenorphine in pregnancy and NAS treatment duration for the infant. The mean number of cigarettes consumed correlated significantly with NAS treatment duration for the methadone group. Birth weight for the methadone group was approximately 200 g above international findings despite high doses during pregnancy.
Maternal methadone/buprenorphine dose predicted neither the occurrence nor the need for NAS treatment for the infant.
To determine the effects of human immunodeficiency virus (HIV) infection on pregnancy outcomes, we prospectively studied female intravenous drug users in a methadone program in New York City. Of 191 women with HIV status known prior to pregnancy, 17 (24%) of 70 seropositives and 26 (22%) of 121 seronegatives became pregnant during 28 months of follow-up. Including 54 additional women first tested for HIV antibody after becoming pregnant, 125 pregnancies were studied in 97 women (39 seropositive, 58 seronegative). None of the seropositive pregnant women had advanced HIV-related disease at entry, and only one developed symptomatic disease (oral candidiasis) during pregnancy. No differences were observed between groups in the frequency of spontaneous or elective abortion, ectopic pregnancy, preterm delivery, stillbirth, or low-birth-weight births. Among women giving birth to live infants, seropositives were more likely than seronegatives to be hospitalized for bacterial pneumonia during pregnancy and had an increased tendency for breech presentation, although these events were infrequent. There were otherwise no differences between groups in the occurrence of antenatal, intrapartum, or neonatal complications. Results suggest that asymptomatic HIV infection is not associated with a decreased pregnancy rate or an increased risk of adverse pregnancy outcomes in intravenous drug users, and that an acceleration in HIV-disease status during pregnancy is uncommon.
(JAMA. 1989;261:1289-1294)
This study examined gender differences in heroin users who first received MMT. Compared with men, female heroin users were younger and more likely to be unemployed, to have family members using illicit substances, to initiate heroin use at a younger age, to begin MMT earlier after starting heroin use, to have methamphetamine use, to initiate methamphetamine use at a younger age, and to report a child-raising burden and a prior history of traumatic experiences. Men were more likely to have use of betel quid, and to initiate alcohol, nicotine and betel quid use at a younger age than women.
Objective:
The purpose of this study was to analyze the obstetric and neonatal impact of an opioid detoxification program during pregnancy, as well as to examine variables associated with successful opioid detoxification.
Study design:
This is a retrospective cohort study of women electing inpatient detoxification and subsequently delivering at our hospital from Jan. 1, 2006, through Dec. 31, 2011. Detoxification was considered successful if women had no illicit drug supplementation at the time of delivery. Maternal characteristics were ascertained by chart review and analyzed for variables associated with success. Obstetric and neonatal outcomes were also assessed based on maternal success at delivery.
Results:
Of the 95 women during the study period with complete data, 53 (56%) were successful. There were no demographic or social risk factors identified associated with success. Women with successful detoxification at delivery had longer inpatient detoxification admissions (median 25 vs 15 days, P < .001) and were less likely to leave prior to completion of the program than women who had relapsed at delivery (9% vs 33%, respectively, P < .001). Infants of mothers who were successfully detoxified had shorter hospitalizations (median 3 vs 22 days, P < .001), lower maximum neonatal abstinence syndrome scores (0 vs 8.3, P < .001), and were less likely to be treated for withdrawal (10% vs 80%, P < .001).
Conclusion:
Opiate detoxification in pregnancy requires a significant time commitment and extended treatment, however, can be successfully achieved in compliant parturients. Importantly, maternal demographics and drug histories do not portend success, supporting continued opiate detoxification being offered to all women expressing intent.
To assess the maternal and neonatal outcomes of pregnant women enrolled on a Methadone Substitution Programme (MSP).
Retrospective cohort study.
Maternity unit of a London teaching hospital and tertiary referral centre.
Pregnant women on a MSP whose antenatal care and delivery was at St Thomas' Hospital (STH) between January 2005 and March 2008. Controls were non-MSP mothers closely matched for age, parity and delivery date during the same period.
Maternal data was collected from the Liaison Antenatal Drugs and Alcohol Service clinic records and the STH Maternity Unit's computerised database. Neonatal data was extracted from the STH Neonatal database (part of the UK National Neonatal database).
Maternal profiles (age, gravidity, parity, ethnicity, BMI, smoking and alcohol history, relationship and employment history), pregnancy details and mode of delivery. Neonatal outcome measures to include gestation age at delivery, birth weight, head circumference, admission rates and length of stay on Special Care Baby Unit plus Neonatal Abstinence Syndrome (NAS) rates, scoring and treatment.
Compared to the non-MSP mothers (n = 88) the MSP group (n = 44) booked later and had a higher incidence of smoking (6.8 vs. 84.1 %), alcohol consumption (10.2 vs. 34.1 %). As a group, they had adverse social background. The MSP group had a higher relative risk (RR) of premature delivery [RR = 2.5, 95% confidence interval (CI) 1.66-3.88] and had lower birth weight babies (adjusted RR = 2.2; 95% CI 1.31-3.71) with smaller head circumferences (adjusted RR 1.9; 95% CI 1.06-3.38). NAS occurred in 27 % (95% CI 15.0-42.8) of the MSP group. There was no difference in congenital abnormality between the two groups, but caesarean section rate was higher in the control group.
Opiate-addicted mothers have adverse perinatal outcomes even on MSPs. In addition to the drug effect associated social, relationship and accommodation problems should also be addressed as they may affect the outcome. Pregnancy care for these women needs to continue to develop to improve overall outcomes.
To examine opioid replacement therapy in pregnancy and effect on neonatal outcomes, including length of hospital stay for neonatal abstinence syndrome.
Retrospective descriptive study.
Labor and delivery unit and neonatal intensive care unit (NICU), Eastern Maine Medical Center, Bangor, Maine.
One hundred fifty-two opioid-dependent pregnant women on methadone maintenance therapy (MMT) (n = 136) or buprenorphine maintenance therapy (BMT) (n = 16) during pregnancy and their neonates. The neonates were born between January 1, 2005 and December 31, 2007.
A review of the electronic medical record (EMR) was conducted of all opioid-dependent women who were maintained on MMT or BMT at the time of admission for labor and delivery and their neonates.
Maternal methadone dose and concomitant in-utero exposure to benzodiazepines prolonged the length of hospital stay for neonates. Length of stay was shorter in breastfed neonates than formula-fed neonates or neonates who received formula and breast milk. Neonates with prenatal exposure to MMT spent more days in the hospital (21 vs. 14 days) for treatment of neonatal abstinence syndrome (NAS) than infants with prenatal exposure to BMT.
These findings are consistent with previous research on the simultaneous use of methadone and benzodiazepines during pregnancy and provide further direction for the treatment of opioid dependency during pregnancy. Harm reduction strategies for opioid-dependent pregnant women in substance abuse treatment with MMT may one day include guidance on daily treatment doses and recommendations to avoid the concomitant use of benzodiazepines to lessen NAS. Breastfeeding should be recommended to shorten length of stay. Understanding perinatal and neonatal outcomes of pregnant women on methadone or buprenorphine will help to identify optimal treatment for opioid dependency in pregnancy.
Methadone use in pregnancy has been associated with adverse perinatal outcomes and neonatal abstinence syndrome (NAS). This study aimed to examine perinatal outcomes and NAS in relation to (i) concomitant drug use and (ii) methadone dose.
Prospective cohort study.
Two tertiary care maternity hospitals.
A total of 117 pregnant women on methadone maintenance treatment recruited between July 2009 and July 2010.
Information on concomitant drug use was recorded with the Addiction Severity Index. Perinatal outcomes included pre-term birth (<37 weeks' gestation), small-for-gestational-age (<10th centile) and neonatal unit admission. NAS outcomes included: incidence of medically treated NAS, peak Finnegan score, cumulative dose of NAS treatment and duration of hospitalization.
Of the 114 liveborn infants 11 (9.6%) were born pre-term, 49 (42.9%) were small-for-gestational-age, 56 (49.1%) had a neonatal unit admission and 29 (25.4%) were treated medically for NAS. Neonates exposed to methadone-only had a shorter hospitalization than those exposed to methadone and concomitant drugs (median 5.0 days versus 6.0 days, P = 0.03). Neonates exposed to methadone doses ≥80 mg required higher cumulative doses of morphine treatment for NAS (median 13.2 mg versus 19.3 mg, P = 0.03). The incidence and duration of NAS did not differ between the two dosage groups.
The incidence and duration of the neonatal abstinence syndrome is not associated with maternal methadone dose, but maternal opiate, benzodiazepine or cocaine use is associated with longer neonatal hospitalization.
In many biometrical applications, the count data encountered often contain extra zeros relative to the Poisson distribution. Zero-inflated Poisson regression models are useful for analyzing such data, but parameter estimates may be seriously biased if the nonzero observations are over-dispersed and simultaneously correlated due to the sampling design or the data collection procedure. In this paper, a zero-inflated negative binomial mixed regression model is presented to analyze a set of pancreas disorder length of stay (LOS) data that comprised mainly same-day separations. Random effects are introduced to account for inter-hospital variations and the dependency of clustered LOS observations. Parameter estimation is achieved by maximizing an appropriate log-likelihood function using an EM algorithm. Alternative modeling strategies, namely the finite mixture of Poisson distributions and the non-parametric maximum likelihood approach, are also considered. The determination of pertinent covariates would assist hospital administrators and clinicians to manage LOS and expenditures efficiently.
Substance abuse in pregnancy has increased over the past three decades in the United States, resulting in approximately 225,000 infants yearly with prenatal exposure to illicit substances. Routine screening and the education of women of child bearing age remain the most important ways to reduce addiction in pregnancy. Legal and illegal substances and their effect on pregnancy discussed in this review include opiates, cocaine, alcohol, tobacco, marijuana, and amphetamines. Most literature regarding opiate abuse is derived from clinical experience with heroin and methadone. Poor obstetric outcomes can be up to six times higher in patients abusing opiates. Neonatal care must be specialized to treat symptoms of withdrawal. Cocaine use in pregnancy can lead to spontaneous abortion, preterm births, placental abruption, and congenital anomalies. Neonatal issues include poor feeding, lethargy, and seizures. Mothers using cocaine require specialized prenatal care and the neonate may require extra supportive care. More than 50% of women in their reproductive years use alcohol. Alcohol is a teratogen and its effects can include spontaneous abortion, growth restriction, birth defects, and mental retardation. Fetal alcohol spectrum disorder can have long-term sequelae for the infant. Tobacco use is high among pregnant women, but this can be a time of great motivation to begin cessation efforts. Long-term effects of prenatal tobacco exposure include spontaneous abortion, ectopic pregnancy, placental insufficiency, low birth weight, fetal growth restriction, preterm delivery, childhood respiratory disease, and behavioral issues. Marijuana use can lead to fetal growth restriction, as well as withdrawal symptoms in the neonate. Lastly, amphetamines can lead to congenital anomalies and other poor obstetric outcomes. Once recognized, a multidisciplinary approach can lead to improved maternal and neonatal outcomes.
In recent decades there has been an increase in the methadone dosages prescribed for opioid dependent women during pregnancy. Using prospective longitudinal data from a cohort of 32 methadone exposed and 42 non-methadone exposed infants, this study examined the relationship between maternal methadone dose during pregnancy and a range of infant clinical outcomes. Of particular interest was the extent to which any observed associations might reflect the direct causal effects of maternal methadone dose and/or the confounding effects of adverse maternal lifestyle factors correlated with methadone use during pregnancy. Findings revealed the presence of clear linear relationships between the mean methadone dose prescribed for mothers during pregnancy and a range of adverse infant clinical outcomes. With increasing maternal methadone dose there was a corresponding increase in infants' risk of being born preterm, being symmetrically smaller, spending longer periods in hospital and the need for treatment for Neonatal Abstinence Syndrome. After due allowance for potentially confounding maternal health and lifestyle factors, maternal methadone dose during pregnancy remained a significant predictor of preterm birth, growth, and the duration of infant hospitalization post delivery. These findings suggest a need to examine more closely the potential impacts of recent trends towards the use of higher methadone dose levels during pregnancy.
The objectives of this study were to investigate factors associated with the development of neonatal abstinence syndrome (NAS) and to assess the implications for healthcare resources of infants born to drug-misusing women.
Retrospective cohort study from 1 January 2004 to 31 December 2006.
Inner-city maternity hospital providing dedicated multidisciplinary care to drug-misusing women.
Four hundred and fifty singleton pregnancies of drug-misusing women prescribed substitute methadone in pregnancy.
Case note review.
Development of NAS and duration of infant hospital stay.
45.5% of infants developed NAS requiring pharmacological treatment. The odds ratio of the infant developing NAS was independently related to prescribed maternal methadone dose rather than associated polydrug misuse. Breastfeeding was associated with reduced odds of requiring treatment for NAS (OR 0.55, 95% CI 0.34-0.88). Preterm birth did not influence the odds of the infant receiving treatment for NAS. 48.4% infants were admitted to the neonatal unit (NNU) 40% of these primarily for treatment of NAS. The median total hospital stay for all infants was 10 days (interquartile range 7-17 days). Infants born to methadone-prescribed drug-misusing mothers represented 2.9% of hospital births, but used 18.2% of NNU cot days.
Higher maternal methadone dose is associated with a higher incidence of NAS. Pregnant drug-misusing women should be encouraged and supported to breastfeed. Their infants are extremely vulnerable and draw heavily on healthcare resources.
To determine the effects of human immunodeficiency virus (HIV) infection on pregnancy outcomes, we prospectively studied female intravenous drug users in a methadone program in New York City. Of 191 women with HIV status known prior to pregnancy, 17 (24%) of 70 seropositives and 26 (22%) of 121 seronegatives became pregnant during 28 months of follow-up. Including 54 additional women first tested for HIV antibody after becoming pregnant, 125 pregnancies were studied in 97 women (39 seropositive, 58 seronegative). None of the seropositive pregnant women had advanced HIV-related disease at entry, and only one developed symptomatic disease (oral candidiasis) during pregnancy. No differences were observed between groups in the frequency of spontaneous or elective abortion, ectopic pregnancy, preterm delivery, stillbirth, or low-birth-weight births. Among women giving birth to live infants, seropositives were more likely than seronegatives to be hospitalized for bacterial pneumonia during pregnancy and had an increased tendency for breech presentation, although these events were infrequent. There were otherwise no differences between groups in the occurrence of antenatal, intrapartum, or neonatal complications. Results suggest that asymptomatic HIV infection is not associated with a decreased pregnancy rate or an increased risk of adverse pregnancy outcomes in intravenous drug users, and that an acceleration in HIV-disease status during pregnancy is uncommon.
This article discusses extensions of generalized linear models for the analysis of longitudinal data. Two approaches are considered: subject-specific (SS) models in which heterogeneity in regression parameters is explicitly modelled; and population-averaged (PA) models in which the aggregate response for the population is the focus. We use a generalized estimating equation approach to fit both classes of models for discrete and continuous outcomes. When the subject-specific parameters are assumed to follow a Gaussian distribution, simple relationships between the PA and SS parameters are available. The methods are illustrated with an analysis of data on mother's smoking and children's respiratory disease.
Five-hundred-sixty-seven heroin addicts admitted to methadone maintenance treatment programs in southern California were included in the present analysis. Systematic comparisons were made between women and men for Anglo and Chicano subpopulations. The behaviors compared focused on initial drug use and other antecedent behaviors during the year prior to initiation of heroin use including interpersonal relationships, other substance use, drug dealing, legal income, and various criminal behaviors. Unlike men, the initial use of heroin by women was highly influenced by a man, especially by a sex partner who is often a daily heroin user. On the other hand, many women (like men) reported self-initiation of heroin use, multiple drug use, and drug dealing, thus demonstrating that they took an active role in their drug involvement. Other differences between men and women for antecedent behaviors prior to narcotics use appear to be related to traditional expectations about gender roles in American society.
The process and correlates of addiction prior to treatment are examined for a sample of 546 women and men methadone maintenance clients. Narcotic addiction careers for women (defined both as from first daily use to first treatment intervention, and from first daily use to last daily use of heroin) were shorter than those for men, and women entered treatment earlier. However, the narcotic drug use patterns for women were not substantially different from those for men (including mean percentage of time using, number of times abstinent, number of relapses, and so forth). Narcotics use for many women was influenced by a spouse or partner, but some also reported increased use for hedonistic reasons. Criminal behaviors increased for both women and men after addiction, and the major sex difference was the type of crime committed. Differences for women and men for employment, welfare, and interpersonal relationships reflected patterns found in the larger society.
This paper is devoted to a discussion of the treatment process as it is experienced by women heroin addicts. We begin by looking at the treatment scene and modes of treatment, including detoxification and methadone maintenance. Next, we analyze the structural problems encountered by women desiring treatment. Finally we discuss the deleterious aspects of treatment and how repeated recidivism stemming from the treatment's structure serves to lock women into the heroin life by actualizing the 'once a junkie, always a junkie' prophecy.
The purpose of this study was to identify factors related to pregnancy and childbirth that might be predictive of a patient's length of stay after delivery and to model variations in length of stay.
California hospital discharge data on maternity patients (n = 499,912) were analyzed. Hierarchical linear modeling was used to adjust for patient case mix and hospital characteristics and to account for the dependence of outcome variables within hospitals.
Substantial variation in length of stay among patients was observed. The variation was mainly attributed to delivery type (vaginal or cesarean section), the patient's clinical risk factors, and severity of complications (if any). Furthermore, hospitals differed significantly in maternity lengths of stay even after adjustment for patient case mix.
Developing risk-adjusted models for length of stay is a complex process but is essential for understanding variation. The hierarchical linear model approach described here represents a more efficient and appropriate way of studying interhospital variations than the traditional regression approach.
This study documents the costs of heroin addiction in the United States, both to the addict and society at large. Using a cost-of-illness approach, costs were estimated in four broad areas: medical care, lost productivity, crime, and social welfare. We estimate that the cost of heroin addiction in the United States was US11.5 billion (53%), criminal activities US5.0 billion (23%), and social welfare US$0.1 billion (0.5%). The large economic burden resulting from heroin addiction highlights the importance of investment in prevention and treatment.
To probe recent evidence on apparent excess occurrence of marijuana dependence when marijuana smoking starts in adolescence.
A national sample of recent-onset marijuana users was identified within public data files of the National Household Survey on Drug Abuse (NHSDA), 1995-98 (1,866 adolescents and 762 adults).
Marijuana dependence was assessed via seven standardized questions about its clinical features, such as being unable to cut down. Multivariate response models (GLM/GEE and MIMIC) were used to evaluate adolescent excess risk and possible item biases.
Among people who had just started to use marijuana, clinical features of marijuana dependence occurred twice as often among adolescents compared to adults, even with statistical adjustment for other covariates (P < 0.01 from GLM/GEE). MIMIC analyses suggest that adolescent-onset users have somewhat higher levels of marijuana dependence, and they also provide evidence of age-associated response bias for some but not all clinical features of marijuana dependence. That is, even with level of marijuana dependence held constant, adolescent recent-onset users were more likely than adults to report being unable to cut down (P = 0.01) and tolerance (P = 0.029).
Nosologic, methodological and substantive reasons for observed age-related excess in occurrence of marijuana dependence problems among early onset users deserve more attention in future research.
Infants with neonatal abstinence syndrome (NAS) may require a prolonged neonatal unit admission, which has implications for both their families and bed occupancy. The aim of this study was to test the hypothesis that the duration of neonatal unit stay would be influenced by the type of maternal drug use and particularly prolonged for the infants whose mothers had taken methadone with other substances.
The medical records of infants born at term who were admitted consecutively to a neonatal unit because of NAS were reviewed. Data were collected regarding antenatal and neonatal factors likely to affect neonatal stay. Comparisons were then made between three groups of infants: those whose mothers took methadone alone, methadone plus other drugs or non-methadone opioids.
Level three neonatal intensive care unit.
Forty-one infants with a median gestational age of 39 (range 37-42) weeks.
The 41 infants had a median duration of admission of 30 (range 3-68) days. Thirty-six of the infants required treatment for NAS; their median duration of treatment was 29 (range 6-68) days. The duration of stay and requirement for treatment were greater in the infants exposed to methadone and other drugs compared to those exposed to non-methadone opiods only (P = 0.0212, P = 0.0343, respectively). The duration of stay without requirement for treatment was also longest in the methadone plus other drugs group (P = 0.0117).
Prolonged treatment and neonatal unit stay are influenced by the type of maternal drug abused.
This article examines patterns of methadone maintenance treatment entry among 9018 adult women injection drug users (IDUs), with special attention to parental-status differences. The data originate from a statewide drug-treatment database covering all women IDUs who entered drug treatment in the State of Massachusetts over a four-year period. Through the use of logistic regression analysis, the study found that among these women IDUs, those who resided with their children were significantly more likely to enter methadone maintenance than women who were mothers but did not reside with their children. Mothers residing with their children were 73% more likely to enter methadone maintenance than mothers who do not reside with their children. The authors discuss specific programmatic and policy implications including the need to determine whether methadone maintenance should be promoted as an alternative drug treatment option in order to preserve family unification or promote family reunification.
Significant gender differences exist in the prevalence of substance use disorders in the United States. There is a trend among boys and girls aged 12 to 17 years toward comparable rates of use and initiation for alcohol, cocaine, heroin, and tobacco. If this trend continues, over time there may be a narrowing of the male-to-female prevalence ratios of substance abuse in the older age groups. This possibility is particularly disturbing because women have a heightened vulnerability to medical, physical, mental, and social consequences of substance use. Women also carry additional unique risks during pregnancy because of the effect on neonates. In addition, they have certain gender-specific cancer risks. Given this and the declining age of initiation of substance use in women, prevention and treatment efforts especially geared toward women (eg, education of all medical and paramedical staff, screening in primary care clinics, detection of drug use early in pregnancy or before conception, brief interventions and treatment programs that integrate women's needs) are exceedingly important to stop and ultimately reverse this growing trend.
Maternal tobacco consumption during pregnancy has been associated with lower birth weight infants, preterm births, intrauterine growth retardation, smaller head circumference and increase in morbidity, yet few studies have examined the role tobacco has on the opiate neonatal abstinence syndrome (NAS). This study examined the effect of prenatal tobacco exposure on NAS for infants born to mothers maintained on methadone during gestation. Twenty-nine pregnant women and their newborn infants participated in this study. Tobacco exposure was based on maternal self-report with 16 women reporting cigarette consumption of 10 or less per day and 13 reporting smoking 20 cigarettes or more a day. The onset, peak, and duration of NAS were examined. Results showed that infants born to mothers who reported smoking 20 or more cigarettes per day had significantly higher NAS peak scores of 9.8 versus 4.8, and took longer to peak (113.0 h versus 37.8 h), than light smokers of 10 or fewer cigarettes per day. We concluded that tobacco use in conjunction with methadone plays an important role in the timing and severity of NAS in prenatally exposed infants.
Although methadone maintenance is the standard treatment of opiate addiction in pregnancy, opinion as to its utility is divided. The aim of this study was to analyze polydrug abuse, pregnancy outcome and fetomaternal complications among pregnant women in a major Swiss methadone maintenance program.
Prospective data collection of all pregnant opiate addicts and their neonates from 1996 to 2001.
Maternal complications occurred in 73% and fetal complications in 34% of the pregnancies. The average methadone dose at delivery in the 89 pregnancies was 40.9 +/- 32.7 (0-150) mg/day. Sixty-four percent of the women were co-users of cocaine and/or heroin. Birthweight was lower in polydrug abusers than in near-exclusive methadone users (p = 0.001).
The high rate of maternal complications demonstrates the need for further improvement in antenatal management of opiate addiction in pregnancy. Methadone maintenance is inefficient in preventing pregnancy exposure to additional illicit drug consumption. Additional illicit heroin and/or cocaine abuse does not seem to increase the incidence of fetomaternal complications during pregnancy, but reverses the positive impact of methadone on birthweight. Heroin-assisted treatment may be a more effective method of minimizing the use of street drugs.
Opiate use in pregnancy is on the increase. There are a number of complications associated with this problem but current data from UK centres are sparse.
A retrospective study.
A North of England Hospital.
Maternal and neonatal case records were studied and a standard data set completed.
Maternal and neonatal outcomes were classified by the woman's drug usage at the end of pregnancy.
One hundred and ten babies born to 108 women were studied and 41% had evidence of previous exposure to the hepatitis C virus. Women who took heroin in later pregnancy were significantly more likely than women who were stabilised on methadone to have a baby who needed morphine (40% versus 19%), had higher mean maximum neonatal abstinence scores (NAS) (5.8 versus 4.7) and stayed in the neonatal unit significantly longer (mean 17.2 days versus 11.8 days). There were two neonatal deaths and the overall rate of prematurity was 29%.
The outcome for pregnancy in women who use opiates is complicated by high rates of prematurity and neonatal death. Women who used heroin in later pregnancy had babies who developed more severe NAS and needed a longer hospital stay than women who used only methadone.
Delivery of methadone maintenance treatment (MMT) varies considerably between service providers, but the reasons for this are unclear. This two-phase study involved a controlled investigation of factors that influence clinical decision making by methadone-prescribing physicians in regard to three decision-making scenarios: (1) individuals seeking induction into MMT and existing patients seeking (2) replacement and (2) takeaway methadone doses. In phase 1, physicians (n = 17) rated the diagnostic merit of 87 patient factors for each scenario. Ratings suggested that decisions are influenced by a range of subjective and "nonmedical" patient factors (e.g., contact with drug subculture, appearance, employment status, social support, having children), in addition to more conventional information sources regarding patients' medical and treatment status (e.g., being pregnant, urinalysis evidence of opioid and poly drug use, signs of opioid withdrawal). Phase 2 (n = 296) investigated relationships between physician characteristics and responses to randomized-controlled case vignettes (decisions and confidence ratings) in which the amount and type of diagnostic and nondiagnostic patient information was controlled. Vignette responses were significantly related to physician characteristics (e.g., professional orientation, location, and experience) independent of the patient information provided. Delivery of MMT may vary due to the diversity of patient factors that influence decisions and variability between physicians in the way such information is used to form judgments. Training programs for methadone prescribers should account for these sources of potential variability in treatment management.
To examine the obstetric and perinatal outcomes for women with a drug-related hospital admission during pregnancy.
Antenatal and birth admissions to New South Wales (NSW) hospitals from the NSW Inpatient Statistics Collection were linked to birth information from the NSW Midwives Data Collection over a 5-year period (1998-2002).
Birth admissions were flagged as positive for drug use where a birth admission or any pregnancy admission for that birth involved an opioid, cannabis or stimulant-related International Classification of Diseases version 10 Australian modification (ICD-10AM) code.
A total of 416 834 live births were analysed over a 5-year period (1998-2002). Of these, 1974 pregnancies had an opioid ICD-10AM diagnosis recorded, 552 a stimulant-related ICD-10AM and 2172 a cannabis ICD-10AM diagnosis. Births in each of the drug groups were to women who were younger, had a higher number of previous pregnancies, were indigenous, smoked heavily and were not privately insured. These women also presented later in their pregnancy to antenatal services and were more likely to arrive at hospital unbooked. Neonates born to women in each of the drug groups were more likely to be premature and were admitted to neonatal intensive care and special care nursery more often, with neonates born to women in the opioid group admitted most often.
Linked population level administrative data is a powerful method for examining the maternal and neonatal outcomes associated with the use of specific illicit drugs during pregnancy.
To examine the association between retention in methadone treatment during pregnancy and key neonatal outcomes.
Client data from the New South Wales Pharmaceutical Drugs of Addiction System was linked to birth information from the NSW Midwives Data Collection and the NSW Inpatient Statistics Collection from 1992 to 2002.
Obstetric and perinatal characteristics of women who were retained continuously on methadone maintenance throughout their pregnancy were compared to those who entered late in their pregnancies (less than 6 months prior to birth) and those whose last treatment episode ended at least 1 year prior to birth.
There were 2993 births to women recorded as being on methadone at delivery, increasing from 62 in 1992 to 459 births in 2002. Compared to mothers who were maintained continuously on methadone throughout their pregnancy, those who entered treatment late also presented later to antenatal services, were more likely to arrive at hospital for delivery unbooked, were more often unmarried, indigenous and smoked more heavily. A higher proportion of neonates born to late entrants were born at less than 37 weeks gestation and were admitted to special care nursery more often.
Continuous methadone treatment during pregnancy is associated with earlier antenatal care and improved neonatal outcomes. Innovative techniques for early engagement in methadone treatment by pregnant heroin using women or those planning to become pregnant should be identified and implemented.
The objective of this study was to determine the population prevalence and correlates of neonatal abstinence syndrome among neonates born to women on methadone, using a cross-sectional analysis of linked population health data. A total of 2941 live births to women actively on methadone at delivery were analysed over an 11-year period (1992 - 2002). Of these births, 796 neonates (27%) were diagnosed with an International Classification of Diseases - 9CM (ICD-9CM) or International Classification of Diseases ICD - 10AM (ICD-10AM) diagnosis related to neonatal withdrawal from exposure to opiates in utero (NAS). There were significant differences found between mothers whose neonates did and did not receive an International Classification of Diseases NAS-related diagnosis. Mothers of neonates with a NAS-related diagnosis had a higher number of previous pregnancies, were more likely to be indigenous, to smoke more heavily and were more likely to present for delivery unbooked. Neonates diagnosed with NAS were admitted to Special Care Nursery more often. NAS is diagnosed less frequently using International Classification of Diseases (ICD) codes than when using clinical scales measuring opiate-related neonatal withdrawal. This suggests that NAS may be under-represented in hospital morbidity databases that use ICD codes to quantify patient throughput and in some circumstances this may result from under-detection of the condition. Future research should therefore seek to determine the validity of NAS recording in hospital morbidity databases reliant on the use ICD codes.
The present article is an update on the effects of drug abuse on pregnancy outcome.
Substance abuse in pregnancy is on the increase worldwide. Simultaneously, there is great variability in prevalence rates in different countries, regions of countries and in different ethnic groups. In the United States nearly 90% of drug-abusing women are of reproductive age. Substances most commonly abused in pregnancy include cocaine, amphetamines, opioids, marijuana, ethanol, tobacco, caffeine, and toluene-based solvents. Polysubstance abuse is very common.
Substance abuse in pregnancy is associated with significant maternal and fetal morbidity. Risk factors suggesting substance abuse in pregnancy include lack of prenatal care, history of premature labor, and cigarette smoking. In the United States the American College of Obstetricians and Gynecologists has made multiple recommendations regarding management of parturients with drug abuse during pregnancy. Women who acknowledge use of illicit substance during pregnancy should be counseled and offered necessary treatment. The American College of Obstetricians and Gynecologists also acknowledged that some states consider intrauterine fetal drug exposure to be a form of child neglect or abuse under the law.
Influ-ence of site differences between urban and rural American and Central European C
- A Baewert
- R Jagsch
- B Winklbaur
- G Kaiser
- K Thau
- A Unger
Baewert, A., Jagsch, R., Winklbaur, B., Kaiser, G., Thau, K., Unger, A., et al. (2012). Influ-ence of site differences between urban and rural American and Central European C.-Y. Chen et al. / International Journal of Drug Policy 26 (2015) 191–198 opioid-dependent pregnant women and neonatal outcome characteristics. Euro-pean Addiction Research, 18(3), 130–139.
The economic costs of heroin addiction in the United States. Drug and Alcohol Depen-dence
- Mark
- Woody L Tami
- E George
- Juday
- Tim
- Herbert D Kleber
Mark, Tami L., Woody George, E., Juday, Tim, & Kleber, Herbert D. (2001). The economic costs of heroin addiction in the United States. Drug and Alcohol Depen-dence, 61(2), 195–206.
The economic costs of heroin addiction in the United States. Drug and Alcohol Dependence
- Tami L Mark
- E Woody George
- Tim Juday
- Kleber
- D Herbert
Mark, Tami L., Woody George, E., Juday, Tim, & Kleber, Herbert D. (2001). The
economic costs of heroin addiction in the United States. Drug and Alcohol Dependence, 61(2), 195-206.