Strategies to prevent or reduce OUD in pregnant women
There are multiple risks to OUD in pregnancy. Untreated addiction to illicit opioids is associated with lack of prenatal care, risk of infectious disease, criminal activity and arrest, maternal trauma, loss of child custody, depression, under-nutrition, increased risk of fetal growth restriction, placental abruption, stillbirth and intrauterine passage of meconium.7,9 Neonatal abstinence syndrome (NAS) is a result of in utero opioid exposure, and subsequent post-delivery withdrawal is characterized by excessive crying, increased muscle tone, tremors, sweating, poor feeding, sleep disturbances and gastrointestinal dysfunction. The occurrence of NAS syndrome increased 5-fold between 2000 and 2012.7
As in the case of non-pregnant women, the best strategy to prevent occurrence of OUD in pregnant and postpartum women is to minimize or eliminate exposure to opioids in the acute pain setting. In my experience, it is rarely necessary to prescribe opioids after discharge following a vaginal delivery. If there are complications such as severe perineal trauma necessitating opioid therapy, limit duration to ≤ 3 days of a low-dose intermediate-release agent. Similarly, I rarely send patients home on opioids after an uncomplicated cesarean delivery, but again if wound complications necessitate such therapy, it should be limited to ≤ 3 days of a low-dose intermediate-release agent. As an alternative, I would prescribe NSAIDs.
For pregnant women with preexisting OUD, MAT with methadone or buprenorphine is the preferred management strategy since MAT protects the fetus from repeated withdrawal, ensures the woman stays engaged in the health care system, avoids infectious and other risks of illicit opioid use, and promotes prenatal care.7,9 Buprenorphine may be the preferred MAT agent. First, it is a partial agonist lowering abuse potential and making overdose less likely. Second, while methadone can only be dispensed by licensed opioid treatment facilities, buprenorphine can be dispensed in an office setting provided the physician has obtained a DEA waiver. Third, Buprenorphine may be more effective and also appears to induce milder NAS.7 Finally, the combination of buprenorphine and naloxone, designed to reduce the potential for intravenous abuse, appears safe to continue as MAT in pregnancy, though additional studies are needed before recommending its initiation during pregnancy.10
There is a growing consensus that MAT with either methadone or buprenorphine is preferable to medically supervised withdrawal in pregnancy because of the high relapse rates (60% to 90%) associated with withdrawal.7,9 If MAT is unavailable or if a pregnant woman insists on medically supervised withdrawal, it should occur in an inpatient setting under the care of a physician expert in this area.
Women on long-acting naltrexone therapy to maintain abstinence who conceive pose a dilemma. The impact of such therapy on the fetus and pregnancy are largely unknown, although the largest study shows no apparent risk.11 Conversely, risk of relapse after discontinuing this agent is clearly increased. Thus, a detailed discussion with the pregnant patient is needed.
A recent Committee Opinion by the American College of Obstetricians and Gynecologists (ACOG) provides the following advice9:
- Conduct early universal screening for OUD and other substance abuse, ideally at the first prenatal visit, followed by a brief intervention (e.g., short conversation, feedback and advice), and referral for MAT to improve maternal and infant outcomes (SBIR).
- Universal screening should rely on validated screening tools, such as questionnaires (e.g., 4Ps, NIDA Quick Screen, and CRAFFT for women 26 years or younger; - see Committee Opinion for descriptions of these tools ).
- For chronic pain, avoid or minimize use of opioids. Review alternative therapies such as nonpharmacologic approaches (e.g., exercise, physical therapy, behavioral therapy), and non-opioid pharmacologic treatments (e.g., short term acetaminophen therapy or NSAIDs < 28 weeks).
- For pregnant women with OUD, MAT is recommended over medically supervised withdrawal.
- Infants born to women who used opioids during pregnancy should be monitored by a pediatric care provider for NAS.
- Given the unique needs of pregnant women with OUD, consider modifying elements of prenatal care (e.g., expanded sexually transmitted infection testing, providing additional ultrasound examinations to rule out fetal growth restriction, and initiating consultations as needed).
- Before prescribing opioids, ensure opioids are appropriately indicated; discuss risks and benefits of use; review treatment goals; rule out history of substance use and review PDMP to determine whether patients have received prior opioid prescriptions.
- Breastfeeding should be encouraged for women on MAT, who are not using illicit drugs, and who have no other contraindications, such as HIV infection. Women should be counseled about the need to suspend breastfeeding in the event of a relapse.
- Provide postpartum psychosocial support services, including referral to treatment and relapse prevention programs.
- Contraceptive counseling and provision.
This extract was reprinted with permission from Opioid use and opioid use disorder in pregnancy. ACOG Committee Opinion No. 711. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;130:e81–94.