The opioid crisis has finally garnered the attention of federal and state governments, which have implemented much-needed policies such as state prescription drug monitoring programs, improved funding for treatment centers, and increased emergency access to naloxone and anti-abuse medications. However, the best strategy to end this scourge remains prevention. Because prescriptions for opioid analgesia remain the major gateway of abuse, physicians, and particularly ob/gyns must strive to avoid their use altogether for chronic pain management and minimize their use for acute pain management. When opioids are indicated for management of chronic pain in non-pregnant women, CDC guidelines should be followed. In pregnant and postpartum women, again prevention is the key with avoidance of any opioid prescription upon discharge following either vaginal or cesarean delivery. If opioids are indicated after either gynecological or obstetrical surgery, the lowest dose of an intermediate-release formulation should be given for ≤ 3 days. Finally, for pregnant women with an OUD, the optimal approach involves MAT with either methadone or buprenorphine.
1. Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths - United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016 Dec 30;65(5051):1445-1452.
2. Florence CS, Zhou C, Luo F, Xu L. The economic burden of prescription opioid overdose, abuse, and dependence in the United States, 2013. Med Care. 2016 Oct;54(10):901-6.
4. Schuchat A, Houry D, Guy GP Jr. New data on opioid use and prescribing in the United States. JAMA. 2017 Aug 1;318(5):425-426.
5. Rapoport AB, Rowley CF. Stretching the Scope - Becoming Frontline Addiction-Medicine Providers. N Engl J Med. 2017 Aug 24;377(8):705-707.
6. Thomas K, Ornstein C. Insurers putting cost over safety with painkillers. New York Times Monday September 18, 2017.
7. National Academy of Medicine, Committee on Pain Management and Regulatory Strategies to Address Prescription Opioid Abuse, Bonnie RJ, Ford MA, Phillips, Editors. Pain Management and the Opioid Epidemic. The National Academies Press. Washington, DC (prepublication copy)
8. Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2015 Feb 17;162(4):276-86.
9. Committee on Obstetric Practice. Committee Opinion No. 711: Opioid Use and Opioid Use Disorder in Pregnancy. Obstet Gynecol. 2017 Aug;130(2):e81-e94.
10. Poon S, Pupco A, Koren G, Bozzo P. Safety of the newer class of opioid antagonists in pregnancy. Can Fam Physician. 2014 Jul;60(7):631-2, e348-9. English, French. PMID: 25022635
11. Kelty E, Hulse G. A retrospective cohort study of birth outcomes in neonates exposed to naltrexone in utero: A comparison with methadone-, buprenorphine- and non-opioid-exposed neonates. Drugs. 2017 Jul;77(11):1211-1219.