Low-dose buprenorphine induction, unlike traditional methods, does not require that individuals experience at least moderate withdrawal before initiation. This technique has been widely used and studied in the general population; however, research in pregnancy is limited. We aimed to evaluate obstetric and neonatal outcomes after low-dose buprenorphine induction. In this retrospective case series, we reviewed all cases of low-dose induction during pregnancy or within 6 weeks postpartum at an urban academic medical center over a 3-year period. Nine patients started buprenorphine using this method, and all but one completed induction. There was a high rate of treatment retention and no apparent associated adverse neonatal events. Four individuals are in sustained remission and currently parenting. Though further research is needed, low-dose buprenorphine induction appears effective in the obstetric population.

Objective. Clinicians caring for families impacted by substance use disorder often feel uncomfortable assessing for child protective concerns in the setting of non-prescribed parental substance use. This leads to a lack of standardization of care, where some clinicians choose to not ask any questions about the care of children for fear of receiving information that will leave them in an uncomfortable position as a mandated reporter, while others may reflexively report any identification of substance use to child protective services. The primary aim of this descriptive manuscript is to present a framework developed by a multidisciplinary team in a medical setting to address concerns about a recurrence of parental substance use. Design. We highlight the development, implementation, and evolution of a clinical decision-making framework designed to help standardize clinicians' discussions around whether substance use could be affecting a parent's ability to safely care for their children. Discussion. Five main assessment areas are discussed, including: (1) Safety of the child while substance use is occurring; (2) Safety of parental use patterns; (3) Parental treatment engagement; (4) Willingness to escalate treatment services; and (5) Stability of the home environment. We will present a clinical scenario to highlight how the framework is used as an aid to determine action planning with respect to immediate safety concerns, treatment escalation, and opportunities to maximize recovery supports. We discuss the challenges we've experienced and opportunities that arise in attempting to incorporate the principles of harm reduction within the context of assessments of child safety and well-being.

BACKGROUND: A positive urine fentanyl toxicology test may have considerable consequences for peripartum individuals, yet the extent to which fentanyl administration in a labor epidural may lead to such a positive test is poorly characterized.OBJECTIVE: This study aimed to quantify the extent to which neuraxial fentanyl in labor neuraxial analgesia can lead to a positive peripartum maternal or neonatal urine toxicology test.STUDY DESIGN: We performed a prospective cohort study of pregnant participants planning a vaginal delivery with neuraxial analgesia. Participants with a history of substance use disorder, hypertension, or renal or liver disease were excluded. A urine sample was collected before initiation of neuraxial analgesia, each time the bladder was emptied during labor, and up to 4 times postpartum. Neonatal urine was collected once. Urine fentanyl testing was performed using 2 common toxicology testing methods, namely immunoassay and liquid chromatography with tandem mass spectrometric detection.RESULTS: A total of 33 maternal-infant dyads yielded a total of 178 urine specimens. All maternal specimens were negative for fentanyl using liquid chromatography with tandem mass spectrometric analysis and immunoassay before initiation of neuraxial analgesia. Intrapartum, 26 of 30 (76.7%) participants had positive liquid chromatography with tandem mass spectrometry results for fentanyl or its metabolites, and 12 of 30 (40%) participants had positive immunoassay results. Postpartum, 19 of 21 (90.5%) participants had positive liquid chromatograph with tandem mass spectrometric results, and 13 of 21 (61.9%) had a positive immu-noassay result. Of the 13 neonatal specimens collected, 10 (76.9%) were positive on liquid chromatography with tandem mass spectrometry anal-ysis, the last of which remained positive 29 hours and 50 minutes after delivery.CONCLUSION: Neuraxial fentanyl for labor analgesia may lead to positive maternal and neonatal toxicology tests at various times after epidural initiation and cessation and at different rates depending on the testing method used. Caution should be used in interpreting toxicology test results of individuals who received neuraxial analgesia to avoid false as-sumptions about nonprescribed use.

Monthly extended-release buprenorphine subcutaneous injection (BUP-XR) is a newer treatment formulation for use in moderate to severe opioid use disorder. After injection into the subcutaneous tissue of the abdomen, the medication forms a depot to allow for slow release of buprenorphine. As such, a small yet visible and palpable nodule is normal and is expected to decrease in size over the following weeks to months. Given the newness of this medication, it is possible that not all healthcare providers are familiar with this formulation, nor will they interpret the BUP-XR depot as normal findings. Herein, we provide a case report where a patient's BUP-XR depot was misdiagnosed as an abscess, resulting in incision and drainage and disruption of life-saving opioid use disorder treatment. To prevent cases like this in the future, it is important that providers administering BUP-XR properly educate patients on what to expect during treatment with BUP-XR and when to seek care for potential abnormalities. In addition, it is critical that healthcare providers working in other treatment settings are aware of how to properly evaluate BUP-XR injection sites.

OBJECTIVES:Some states, including Massachusetts, require automatic filing of child abuse and neglect for substance-exposed newborns, including infants exposed in-utero to clinician-prescribed medications to treat opioid use disorder (MOUD). The aim of this article is to explore effects of these mandated reporting policies on pregnant and postpartum people receiving MOUD. METHODS:We used modified grounded research theory, literature findings, and constant comparative methods to extract, analyze and contextualize perinatal experiences with child protection systems (CPS) and explore the impact of the Massachusetts mandated reporting policy on healthcare experiences and OUD treatment decisions. We drew from 26 semi-structured interviews originally conducted within a parent study of perinatal MOUD use in pregnancy and the postpartum period. RESULTS:Three themes unique to CPS reporting policies and involvement emerged. First, mothers who received MOUD during pregnancy identified mandated reporting for prenatally prescribed medication utilization as unjust and stigmatizing. Second, the stress caused by an impending CPS filing at delivery and the realities of CPS surveillance and involvement after filing were both perceived as harmful to family health and wellbeing. Finally, pregnant and postpartum individuals with OUD felt pressure to make medical decisions in a complex environment in which medical recommendations and the requirements of CPS agencies often compete. CONCLUSIONS FOR PRACTICE:Uncoupling of OUD treatment decisions in the perinatal period from mandated CPS reporting at time of delivery is essential. The primary focus for families affected by OUD must shift from surveillance and stigma to evidence-based treatment and access to supportive services and resources.

Weekly and monthly CAM2038 (Brixadi®) extended-release subcutaneous buprenorphine (XR bup) has been available in Europe and Australia for several years and was approved by the Food and Drug Administration in May 2023. Little is known about the clinical experience of patients and providers using this new medication during prenatal care. Two cases of pregnant persons with opioid use disorder receiving weekly XR bup in an ongoing randomized multi-site outpatient clinical trial are presented along with a brief review of the pharmacology and literature on XR bup formulations. The cases in pregnancy illustrate how treatment with the weekly formulation is initiated including how to make dose adjustments, which may be necessary given the longer half-life; it takes 1 month to achieve steady state. Injection site pain with medication administration was time limited and managed readily. Other injection site reactions experienced included subcutaneous erythema and induration that was delayed in onset and typically mild, resolving with minimal intervention. Delivery management and breastfeeding recommendations while on weekly XR bup were not different compared to sublingual buprenorphine (SL bup). Weekly XR bup is a new treatment for opioid use disorder that may be used in the obstetric population. Obstetric and addiction medicine clinicians should be aware of this new formulation as its use is expected to increase.

To quantify the extent to which neuraxial fentanyl in a labor epidural can lead to a positive peripartum maternal or neonatal urine toxicology test. We performed a prospective study of pregnant participants planning a vaginal delivery with neuraxial anesthesia. Participants with a history of substance use, hypertension, or renal disease were excluded. A urine sample was collected prior to epidural placement, each time the bladder was emptied intrapartum after epidural initiation, and up to four times postpartum. Neonatal urine was collected once. Urine fentanyl testing was performed with two common toxicology testing methods: immunoassay and Liquid-Chromatography with Tandem Mass Spectrometric detection (LC-MS/MS). 19 maternal-infant dyads were recruited, yielding a total of 94 urine specimens. All maternal samples were negative for fentanyl prior to epidural initiation on immunoassay and LC-MS/MS. During labor, 13/19 (68.4%) participants had a positive fentanyl immunoassay, and 2/19 (10.5%) had a positive LC-MS/MS. Postpartum, 6/9 (66.7%) participants had a positive fentanyl immunoassay, and 3/9 (33.3%) participants had a positive LC-MS/MS. Individual maternal toxicology test results at timed intervals after epidural initiation and cessation are shown in the Table. The number of positive specimens at timed intervals pre- and post-epidural initiation are shown in the Figure. 1/8 (12.5%) neonatal urine samples were positive for fentanyl on LC-MS/MS 11 hours after delivery. Neuraxial fentanyl for labor analgesia may lead to positive maternal and neonatal urine toxicology tests at varying times after epidural initiation and cessation and at different rates depending on the testing method used. A positive maternal or neonatal urine fentanyl test may have significant consequences for pregnant women receiving a toxicology test as these results may be falsely attributed to non-prescribed opioid use. Further investigation will evaluate maternal and pharmacologic factors associated with a positive test to further inform patient counseling after positive fentanyl test results.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Introduction: Medications to treat opioid use disorder (MOUD) during pregnancy and in the postpartum period remain underutilized. A need exists to enhance our understanding of modifiable factors, facilitators, and barriers to MOUD utilization and adherence in the perinatal period to improve maternal and child outcomes.Methods: The study conducted semi-structured qualitative interviews with recently pregnant people with opioid use disorder (OUD) to explore experiences as a pregnant and/or parenting person with OUD, perceptions of enabling factors and barriers to treatment utilization, incentivizing factors for maintaining adherence, and acceptability of ongoing supports to sustain treatment adherence. The study team used constant comparative methods to analyze transcripts and develop the codebook. The team double coded the transcripts, with an overall kappa coefficient of 0.88.Results: The study team interviewed twenty-six women on average 10.1 months after delivery. All women had some prior experience using MOUD. Four unique themes emerged as barriers to medication utilization and adherence in the perinatal period: 1) Lack of agency and autonomy surrounding medication decisions because pregnancy or parenting status affected treatment adherence; 2) Hesitancy to use MOUD to minimize risk of newborn withdrawal; 3) Concern about increased scrutiny and potential loss of custody due to mandated child protective services reporting for opioid-exposure at delivery in Massachusetts; and 4) Perception that treatment environments, particularly methadone clinics, did not provide gender-responsive or equitable care, and standardized, inflexible visit regulations were particularly difficult to comply with in the early postpartum period.Conclusions: Women with OUD experienced a double bind when making perinatal treatment decisions, describing pressure to use MOUD with negative consequences after delivery. Key areas for possible intervention emerged from interviews. These areas include improving uptake of shared decision-making to increase patient autonomy

Bernstein, Sarah N. MD; Peckham, Alyssa M. PharmD, BCPP; Schiff, Davida M. MD; Gray, Jessica R. MD Author Information

Background: In clinical trial settings, extended-release buprenorphine (XR-BUP) is noninferior to sublingual buprenorphine and may offer some advantages. However, real-world experiences of XR-BUP are limited and outcomes are unknown for low-threshold clinics with high-risk populations. Practical guidance is lacking on overcoming treatment challenges, such as inability for some to stabilize on sublingual (SL) BUP for seven days prior to XR-BUP and ongoing craving/withdrawal symptoms during treatment. Methods: Retrospective case series of a convenience sample of 40 serial adults with opioid use disorder (OUD) treated with XR-BUP from Massachusetts General Hospital bridge clinic from February 1, 2019, to July 31, 2019. Results: Patients were mostly male (67.5%), non-Hispanic white (97.5%), unstably housed (77.5%), and average age of 32.1 years old. The average SL BUP dose prior to XR-BUP was 18.6 mg (standard deviation [SD] = 5; range 8-32) for an average treatment duration of 105 days (SD = 191; range 1-810). Ten (25%) patients received SL BUP for fewer than the seven recommended days (mean = 3.7, SD = 1.4, range = 1-6). Standard induction dosing was administered to 30%, empiric high-dose XR-BUP (300 mg monthly) was administered to 25%, and 55% were treated with supplemental SL BUP ranging from 4 to24mg, daily or as needed, for varying time periods. At the end of data collection, 65% remained on XR-BUP, 30% discontinued XR-BUP, and one patient was lost to follow-up. Acute care utilization rates were similar between patients who continued XR-BUP versus discontinued at 18.5% and 16.6%, respectively (chi 2 = 0.02, p-value = 0.89). Toxicology was negative for other opioids in 65% of patients throughout treatment. There were no reports of overdose, withdrawal after use of opioids, or precipitated withdrawal after subsequent XR-BUP. Patients' most cited reason for discontinuing XRBUP was a preference for SL BUP. Conclusion: This real-world evaluation of XR-BUP in a low-threshold clinic found that treatment was feasible, well tolerated, and outcomes were good, with most individuals choosing to continue treatment and a majority with no evidence of ongoing opioid use or precipitated withdrawal.

Objective We sought to 1) identify models of integrated care that offer medical care and social services for children and families impacted by opioid use disorder (OUD) in the postpartum year; and 2) describe how each program was developed, designed, and sustained, and explore facilitators and barriers to implementation of a dyadic, two-generation approach to care. Methods In-depth semi-structured interviews (n = 23) were conducted with programs for women and children affected by OUD across North America. Using a phenomenologic approach, key program components and themes were identified. Following thematic saturation, these results were triangulated with experts in program implementation and with a subset of key informants to ensure data integrity. Results Five distinct types of programs were identified that varied in the degree of medical and behavioral care for families. Three themes emerged unique to the provision of dyadic care: 1) families require supportive, frequent visits with a range of providers, but constraints around billable services limit care integration across the perinatal continuum; 2) individual program champions are critical, but degree and reach of interdisciplinary care is limited by siloed systems for medical and behavioral care; and 3) addressing dual, sometimes competing, responsibilities for both parental and infant health following recurrence of parental substance use presents unique challenges. Conclusions The key components of dyadic care models for families impacted by OUD included prioritizing care coordination, removing barriers to integrating medical and behavioral services, and ensuring the safety of children in homes with ongoing parental substance use while maintaining parental trust.

Pregnant and postpartum patients with substance use disorders (SUD) often have other co-occurring mental health disorders. Complications of substance use and mental health conditions, such as overdose and suicide, are a significant contributor to maternal morbidity and mortality. For individuals dually diagnosed with SUD and other mental health disorders, the perinatal period can be both a motivating and a vulnerable period for care. Barriers to optimal care include, but are not limited to, lack of screening, lack of referrals for care, a limited number of psychiatric providers available to care for pregnant patients, and stigma around mental health and addiction care in pregnancy. In this review, we discuss approaches to low-barrier perinatal psychiatric care for women with SUD to promote engagement in care. We review (1) appropriate psychiatric assessment and diagnostic work-up; (2) treatment planning incorporating shared-decision making, non-punitive and culturally sensitive patient-centred care, and principles of harm reduction with a focus on psychopharmacology, and (3) the benefits of an integrated and collaborative multidisciplinary care model for this subpopulation of vulnerable patients.

Objective: National guidelines advise against breastfeeding for women who use nonprescribed substances in the third trimester. This reduces the number of women who are supported in breastfeeding initiation despite limited evidence on the prognostic value of third trimester substance use. We sought to examine the degree to which prenatal nonprescribed substance use is associated with non-prescribed use postpartum. Methods: Retrospective cohort study of pregnant women with opioid use disorder on methadone or buprenorphine between 2006 and 2015. Nonprescribed use was defined by a positive urine drug testing (UDT). Sensitivity, specificity, positive predictive value, and negative predictive value were calculated comparing 3 prenatal periods with postpartum UDT results. Generalized estimating equations were used to examine the extent to which prenatal nonprescribed use was associated with postpartum use. Results: Included were 545 deliveries by 503 women. Mean age was 28.3 years, 88% were White/non-Hispanic, 93% had public insurance, and 43% received adequate prenatal care. The predictive value of UDT's 90 to 31 days before delivery, 30 to 0 days before delivery, and at delivery showed low sensitivity (44, 26, 27%, respectively) and positive predictive value (36, 36, 56%, respectively), but higher negative predictive value (80, 85, and 78%, respectively), P-values all <0.05. In the final adjusted model, only nonprescribed use at delivery was significantly associated with postpartum nonprescribed use. Conclusions: Nonprescribed use at delivery was most strongly associated with postpartum use compared with earlier time periods currently prioritized in guidelines. In women with opioid use disorder prenatal UDT results alone are insufficient to guide breastfeeding decisions.

Background: Opioid agonist treatment (OAT) in pregnancy reduces overdose risk, drug use, increases prenatal care engagement, and improves birth outcomes. Yet many pregnant women lack access to adequate treatment. OAT, while incarcerated, reduces subsequent overdose risk, improves continuation to treatment on release, and reduces recidivism. Yet most correction facilities do not follow evidence-based guidelines for treatment, resulting in destabilization and overdose. This case is unique in illustrating 1 example of a patient who is justice-involved during pregnancy and the postpartum period, and highlighting an area of advocacy that is under-reported in the medical literature. Case Presentation: A 28-year-old G2P0010 woman with a history of severe opioid use disorder (OUD) learned she was 13 weeks pregnant after a polysubstance overdose while on methadone treatment. She did not engage in prenatal care, despite many encounters with the healthcare system. Her pregnancy course was marked by polysubstance use, hospitalizations, and incarcerations. While incarcerated, she delivered a healthy baby at 37 weeks, and her parental custody rights were suspended. The obstetrics team successfully advocated with the jail for continuing methadone postpartum due to the increased risk of relapse and overdose on release. After release, she continued methadone treatment with no further illicit opioid use, began to engage in counseling, 12-step meetings, and worked towards custody of her son. Conclusions: The postpartum and postincarceration periods are 2 high-risk periods for women with OUD. OAT in and out of incarceration provided some stability and benefit, in the midst of a prenatal course that was fragmented by polysubstance use, hospitalization, and incarceration. Maintaining and prioritizing access to OAT for patients who are incarcerated is necessary, though not sufficient, to address the high risk of overdose. Empowering healthcare providers to advocate for incarcerated patients with OUD on an individual level is 1 key strategy to optimize addiction treatment for incarcerated people.