Buprenorphine versus Methadone for Opioid Use Disorder in Pregnancy.
Buprenorphine versus Methadone for Opioid Use Disorder in Pregnancy.
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DOI：
10.1056/nejmoa2203318
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发表时间：
2022-12-01
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强烈建议阿片类激动剂治疗用于患有阿片类药物使用障碍的孕妇。丁丙诺啡可能与更有利的新生儿和产妇的结果比美沙酮，但现有的数据是有限的。我们进行了一项队列研究，涉及2000年至2018年期间在美国参加公共保险计划的孕妇，我们检查了接受丁丙诺啡的人与接受美沙酮的人的结果。在妊娠早期（至妊娠第19周）、妊娠晚期（妊娠第20周至分娩前一天）和分娩前30天评估两种药物的暴露情况。使用倾向评分重叠权重调整新生儿和母体结局的风险比以消除混杂因素。该研究的数据来源包括2，548，372例以活产结束的妊娠。在怀孕早期，10 704名孕妇接触丁丙诺啡，4 387名孕妇接触美沙酮。在妊娠晚期，11，272人暴露于丁丙诺啡，5056人暴露于美沙酮（分娩前30天分别为9976人和4597人）。在分娩前30天内暴露于丁丙诺啡的婴儿中，新生儿戒断综合征发生率为52.0%，而暴露于美沙酮的婴儿为69.2%（校正相对危险度为0.73; 95%置信区间[CI]为0.71 - 0.75）。早产发生在14.4%的婴儿暴露于丁丙诺啡在怀孕早期和24.9%的那些暴露于美沙酮（校正相对风险，0.58; 95%CI，0.53 - 0.62）;小于胎龄儿分别为12.1%和15.3%（校正相对危险度，0.72; 95%CI，0.66至0.80）;和低出生体重8.3%和14.9%（校正相对危险度，0.56; 95%CI，0.50至0.63）。在妊娠早期暴露于丁丙诺啡的孕妇中，33.6%发生剖宫产，暴露于美沙酮的孕妇中，33.1%发生剖宫产（调整后的相对危险度为1.02; 95%CI为0.97 ~ 1.08），严重的母体并发症发生率分别为3.3%和3.5（调整后的相对风险，0.91; 95% CI，0.74 - 1.13）。妊娠晚期的暴露结果与妊娠早期的暴露结果一致。妊娠期使用丁丙诺啡与不良新生儿结局的风险低于使用美沙酮相关;然而，接受丁丙诺啡和接受美沙酮的人中不良孕产妇结局的风险相似。（由国家药物滥用研究所资助。
Opioid agonist therapy is strongly recommended for pregnant persons with opioid use disorder. Buprenorphine may be associated with more favorable neonatal and maternal outcomes than methadone, but existing data are limited. We conducted a cohort study involving pregnant persons who were enrolled in public insurance programs in the United States during the period from 2000 through 2018 in which we examined outcomes among those who received buprenorphine as compared with those who received methadone. Exposure to the two medications was assessed in early pregnancy (through gestational week 19), late pregnancy (gestational week 20 through the day before delivery), and the 30 days before delivery. Risk ratios for neonatal and maternal outcomes were adjusted for confounders with the use of propensity-score overlap weights. The data source for the study consisted of 2,548,372 pregnancies that ended in live births. In early pregnancy, 10,704 pregnant persons were exposed to buprenorphine and 4387 to methadone. In late pregnancy, 11,272 were exposed to buprenorphine and 5056 to methadone (9976 and 4597, respectively, in the 30 days before delivery). Neonatal abstinence syndrome occurred in 52.0% of the infants who were exposed to buprenorphine in the 30 days before delivery as compared with 69.2% of those exposed to methadone (adjusted relative risk, 0.73; 95% confidence interval [CI], 0.71 to 0.75). Preterm birth occurred in 14.4% of infants exposed to buprenorphine in early pregnancy and in 24.9% of those exposed to methadone (adjusted relative risk, 0.58; 95% CI, 0.53 to 0.62); small size for gestational age in 12.1% and 15.3%, respectively (adjusted relative risk, 0.72; 95% CI, 0.66 to 0.80); and low birth weight in 8.3% and 14.9% (adjusted relative risk, 0.56; 95% CI, 0.50 to 0.63). Delivery by cesarean section occurred in 33.6% of pregnant persons exposed to buprenorphine in early pregnancy and 33.1% of those exposed to methadone (adjusted relative risk, 1.02; 95% CI, 0.97 to 1.08), and severe maternal complications developed in 3.3% and 3.5%, respectively (adjusted relative risk, 0.91; 95% CI, 0.74 to 1.13). Results of exposure in late pregnancy were consistent with results of exposure in early pregnancy. The use of buprenorphine in pregnancy was associated with a lower risk of adverse neonatal outcomes than methadone use; however, the risk of adverse maternal outcomes was similar among persons who received buprenorphine and those who received methadone. (Funded by the National Institute on Drug Abuse.)