Medication-assisted treatment vs. detoxification for women who misuse opioids in pregnancy: Associations with dropout, relapse, neonatal opioid withdrawal syndrome (NOWS), and childhood sexual abuse.

The American College of Obstetricians and Gynecologists recommends medication-assisted treatment (MAT) for pregnant women who misuse opioids rather than detoxification because of possible relapse and dropout from treatment (ACOG, 2017). In a prospective study, fifty-five pregnant women with an opioid use disorder were offered a choice of MAT or detoxification. Ethical concerns precluded random assignment. We assessed dropout, treatment outcome, relapse, other illicit drug use, infant neonatal opioid withdrawal syndrome (NOWS), and childhood sexual abuse. Of 55 women, 13 initially chose MAT and 42 women chose detoxification. All women received behavioral support. No one dropped out of treatment prior to delivery. All women who chose MAT initially remained on MAT. Of women who chose detoxification, 23% switched to MAT, 30% tapered below initial MAT doses, and 45% fully detoxified by delivery. There was a significant difference in opioid relapse between women on MAT (26%) and those who detoxified (0%), but no differences for other illicit drug use. Infants of women on MAT were more likely to have neonatal NOWS (91%) than infants of women who tapered below initial MAT doses but did not fully detoxify (62%). Infants of mothers who tapered (62%) were more likely to have NOWS than infants of women who fully detoxified (0%). Women on MAT reported significantly lower sexual abuse severity than did women who tapered or detoxified. It is critical to replicate the current findings and to follow up with mothers and their infants postpartum to ascertain the long-term impact of tapering or detoxification during pregnancy.

Pregnant women's history of childhood maltreatment and current opioid use: The mediating role of reflective functioning.

There is an association between the experience of childhood maltreatment and opioid misuse in adults, especially for women. However, we know little about this association in pregnancy, and less about processes that could be the target of interventions to help women better parent their infants. We examined reflective functioning as a putative process. Reflective functioning is the ability to interpret one's own and others' behavior in terms of underlying mental states, e.g., emotions, motivations, and beliefs. We sampled 55 pregnant women who misused opioids and 38 women at high risk due to medical factors, e.g., heart disease. We assessed maltreatment with the Maltreatment and Abuse Chronology of Exposure (MACE; Teicher & Parigger, 2015), and reflective functioning with the Reflective Functioning Questionnaire (RFQ; Fonagy et al., 2016). Maltreatment variables included the sum of severity across all subtypes, number of subtypes experienced, and severity of sexual, physical, and emotional abuse, and of neglect. We created a categorical opioid user group variable: women who used opioids in pregnancy vs. high-risk medical comparisons. We found that women who used opioids in pregnancy had poorer reflective functioning than did high-risk medical comparisons. We also created an opioid use severity scale (ranging from 0 to 3) from urine assays and history of prescribed opioids from medical records. Using Hayes (2012)'s bootstrapping PROCESS macro, we found that reflective functioning mediated the association between all maltreatment variables and opioid use severity. We discuss the results in terms of how best to intervene to improve women's reflective functioning, which may help their ability to parent.

Maternal psychological control, maternal borderline personality disorder, and adolescent borderline features.

Linehan (1993) theorized that the experience of invalidating parenting interacts with emotional vulnerability in the development of borderline personality disorder (BPD). Parental psychological control is a type of invalidating parenting, defined as manipulation by parents of their offspring's psychological and emotional expression and experience (Barber, 1996). In a normative sample of adolescent females, adolescent-reported maternal psychological control was related to maternal borderline symptoms (Zalewski et al., 2014). The current study expanded on these findings to sample mothers with a diagnosis of BPD (n = 28) and normative comparisons (n = 28) with male and female adolescents aged 14-18. We assessed maternal and adolescent self-reported borderline features (affective instability, negative relationships, identity disturbance, and self-harm) and coded maternal psychological control from filmed problem-solving interactions. Controlling for current major depressive disorder and family income, mothers with BPD used more total psychological control with their adolescents in comparison with normative mothers. Further, maternal psychological control was positively associated with all mothers' borderline features and with adolescent affective instability. Finally, we found a significant indirect effect for maternal affective instability between maternal total psychological control and adolescent affective instability. We discuss adolescents' risk of developing BPD themselves and prevention and treatment implications. (PsycINFO Database Record