Mishka Terplan, MD, MPH

Snapshot: Protocol 3 - Opioid Use, Misuse, and Addiction in Pregnancy and Postpartum

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This is the complete chapter on opioids in pregnancy and postpartum from Protocols for High-Risk Pregnancies, 7th Edition, edited by John T. Queenan, MD, Catherine Y. Spong, MD, and Charles J. Lockwood, MD, MHCM.

Full Protocol 3: Opioid Use, Misuse, and Addiction in Pregnancy and Postpartum

Protocols for High-Risk Pregnancies, 7th Edition

As the authors note, today about 50% of heroin users are female, versus less than 20% in the 1970s. At least half of those who present for treatment of opioid use disorder (OUD) are female. Between 1999 and 2014, rates of OUD at delivery and of NAS more than quadrupled. Yet the need for treatment is largely unmet, with only 30% to 70% of pregnant women with opioid addiction reportedly receiving care for it during pregnancy.

Risks associated with opioid use include tolerance, dependence, and overdose-related morbidity and mortality. Symptoms of misuse include taking extra medication, running out of prescriptions early, and crushing and snorting or injecting the substance.

The validated instruments for screening for substance use in pregnancy include the Substance Use Risk Profile-Pregnancy (SURP-P), CRAFFT, 5Ps (parents, peers, partner, pregnancy, past), Wayne Indirect Drug Use Screener (WIDUS), and the National Institute on Drug Abuse (NIDA) Quick Screen. Screening should be done at the first prenatal care visit, every trimester, and postpartum. Urine drug testing is not a substitute for screening.

Methadone—in use in pregnancy since the 1960s—buprenorphine, and naltrexone are the three drugs approved by the US Food and Drug Administration for treatment of OUD. NAS is a possible adverse effect of methadone and buprenorphine but is less severe and of shorter duration with the latter.

Treatment can be done on an outpatient or inpatient basis at any time during pregnancy. Medication must be titrated to treat withdrawal, and dose increases may be needed to control cravings. The goal is a clinically meaningful “blockade” that prevents the patient from feeling the effects of an opioid while receiving treatment for addiction.

Medication for OUD should be continued during labor and delivery. Need for analgesia may be greater in patients addicted to opioids.

NAS is expected and treatable in infants delivered by women who take opioids during pregnancy but the likelihood of it is not associated with the level of in utero exposure.

Women with OUD are at particular risk for recurrence during the postpartum period, making continuing care essential.

READ the complete chapter on opioids in pregnancy and postpartum from 

, edited by John T. Queenan, MD, Catherine Y. Spong, MD, and Charles J. Lockwood, MD, MHCM, now. 

In this protocol, Terplan reviews screening for substance use and diagnosis and management of addiction during pregnancy, labor and delivery, and postpartum. The information is presented against the backdrop of the current opioid crisis. Tables on medication choice and protocols and on risk and protective factors for neonatal abstinence syndrome (NAS) are included.

Snapshot: Protocol 3 - Opioid Use, Misuse, and  Addiction in Pregnancy and Postpartum

Behavioral health refers to the domains of mental health and substance use and is an essential component of wellness. Pregnancy and the postpartum period are times of unique physical, social, and psychologic changes. We will review behavioral health conditions during pregnancy and postpartum with particular attention to the relationship between behavioral health and maternal mortality.

Nearly 1 in 5 pregnancies are complicated by a perinatal mood disorder, such as depression, anxiety, and post-traumatic stress disorder.

 Untreated mood disorders are associated with adverse gestational outcomes and can have lasting clinical and economic effects beyond the perinatal period for mothers and their families.

 for routine screening with validated tools,

 screening is infrequent and treatment is underutilized.

 A recent meta-analysis found that the majority of pregnant women suffering from mood disorders are undiagnosed, less than 1 in 10 receive adequate treatment, and less than 1 in 20 achieve remission.

Overall, pregnant and parenting women use fewer substances than other women, and prenatal substance use decreases with gestational age.

Women who continue to use substances during pregnancy likely have a substance use disorder.

 Opioid use disorder is prevalent in roughly 2% of pregnant women.

 Pharmacotherapy for opioid use disorder, with either methadone or buprenorphine, is recommended during pregnancy

 as it is safe, effective, and associated with improved maternal and neonatal outcomes.

 However, most pregnant women receive no treatment for substance use disorders,

 and only 50% of women in treatment for opioid use disorder receive pharmacotherapy.

Women face a diverse set of medical, personal, and social challenges postpartum.

 In addition, newborn care can be stressful and isolating, sleep is poor, and mood changes, specifically postpartum depression, are common, especially for women with behavioral health conditions.

 Suicide rates increase postpartum, especially among teenagers and those with psychiatric diagnoses.

 For women with substance use disorders, relapse is more common postpartum than during pregnancy,

Amid this challenging time, some women also do not have paid parental leave from their employers, and others lose insurance coverage, especially in states without Medicaid expansion. Even when health insurance is maintained, continuing care is often fragmented and infrequent. Of those who died from self-harm in Colorado, less than half attended a postpartum visit.

 Opioid use disorder pharmacotherapy is rarely initiated postpartum, and treatment begun during pregnancy often lapses following delivery.

Maternal mortality is defined by the Centers for Disease Control and Prevention (CDC) as a maternal death occurring during pregnancy through the first year postpartum. In contrast to other industrialized nations, in the United States, maternal mortality is increasing, driven in part by behavioral health conditions. Maternal Mortality Review Committees in several states have documented suicide and opioid overdose as the leading causes of maternal death, exceeding deaths from hemorrhage, emboli, preeclampsia and sepsis, a fact highlighted in a recent landmark report by the CDC Foundation.

 Roughly 1 in 5 maternal deaths are due to an opioid overdose in the United States, and in contrast to other pregnancy-associated deaths, overdose risk increases throughout the postpartum period.

 Overdose deaths are most likely among women whose substance use went unrecognized throughout pregnancy and delivery. In Colorado, only 17% of women who died of an overdose had any history of addiction documented in their chart.

 To properly address maternal deaths due to overdose, Maternal Mortality Review Committee membership should be expanded to include behavioral health expertise in addition to social service representatives.

It has been well established that pharmacotherapy for opioid use disorder protects against relapse, overdose, and overdose death. Medicines, however, only work when people have access to them. To identify individuals who would benefit from treatment, assessment for substance use, misuse and addiction should be universal across all domains of health care, including preconception and prenatal care.

 Simultaneously, treatment capacity must be expanded; health systems and payers should work towards equitable access to evidence-based treatment services for all women.

Prenatal care is a frequent point of contact with the healthcare system and is structured to maximize screening for conditions that affect delivery and birth outcomes. Hence the frequency of visits increases until delivery but typically encompasses just 1 visit postpartum. This artificial separation of pregnancy from the postpartum period compounds vulnerabilities, especially for women with behavioral health conditions. Recognizing the need to intensify how we address the medical, social, and emotional well-being needs of postpartum women and their families, thought leaders have recently called for re-structuring of the care provided in the “Fourth Trimester.” Rather than a single encounter, postpartum care should be an ongoing process, with earlier and more frequent contact delivering woman-center, tailored care through 12 weeks postpartum.

Chronic behavioral health conditions require continuing care. This is clearly illustrated by the increasing numbers of maternal deaths among women with behavioral health conditions. Beyond the call to provide better care to our postpartum patients, we must also advocate for health insurance coverage to extend until at least 1 year following delivery. Such restructuring would allow clinical and payment structures to align with public health metrics, filling in gaps of coverage encountered more often by vulnerable populations including socioeconomically disadvantaged, racial minority, and adolescent women. Without simultaneous efforts at both the individual and population levels, the unfortunate trends of women entering pregnancy with untreated mental illness and mothers dying from overdose being seen today are only to continue.

The authors report no potential conflicts of interest with regard to this article.

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Women with behavioral conditions need ongoing care through pregnancy and postpartum, but our health care system makes this a challenge

Mishka Terplan, MD, MPH

Articles

Full Protocol 3: Opioid Use, Misuse, and Addiction in Pregnancy and Postpartum

Snapshot: Protocol 3 - Opioid Use, Misuse, and Addiction in Pregnancy and Postpartum

Behavioral health in pregnancy and postpartum