Specialty focus: Obstetrics
Opioid use in pregnancy: High risk and high reward
by Kaylin Klie, MD, MA and Lesley Brooks, MD
In parallel with the national opioid epidemic, opioid use in pregnancy has increased dramatically in the last decade. Pregnant women with substance use are an important population in which to emphasize screening, brief intervention and referral for further assessment and treatment. Pregnancy provides an important opportunity to identify and offer treatment to women who are typically highly motivated for help. Here are some basic recommendations to help improve our identification and assistance provided to pregnant women with substance use.
In alignment with statements from the American College of Obstetricians and Gynecologists and the American Society of Addiction Medicine, universal screening for substance use in pregnancy is recommended as part of comprehensive prenatal care. SBIRT (screening, brief intervention and referral to treatment) is an evidenced-based in-office modality to assess for substance use. Screening must be universal, as opposed to screening based only on factors (scant prenatal care, poverty, etc.), as this type of stereotyped screening can lead to missed opportunities as well as perpetuation of stigma. As substance use disorders are known to be distributed across all racial, ethnic and socioeconomic groups, so must our screening be made available to all pregnant women. There are several validated screening tools for use in pregnancy, including the 4Ps, CRAFFT (ages <26), etc.
Opioid use disorder is a pattern of opioid use that is characterized by cravings, impulsive use and continued use despite harm or consequence. While tolerance and dependence are expected physiological adaptations to repeated opioid exposure, and certainly are typically present in women with opioid use disorders, they may also be found in women without opioid use disorder as well. For this reason, a diagnosis should also depend upon DSM-V specific criteria as above, as well as opioid interference in roles: social problems or inability to fulfill obligations at work, home or school. Many women with opioid use disorder describe using opioids as a “full-time job,” as the short-acting nature of most opioids of abuse require frequent dosing throughout the day, as well as activities necessary to raise adequate funds to ensure a continuous supply to prevent withdrawal.
Not all opioids utilized in pregnancy are illicit. As the overall amount of opioids prescribed for pain in the United States has increased, so has opioid prescribing increased for pregnant women. In 2007, 22.8 percent of women enrolled in Medicaid across 46 states filled an opioid prescription during pregnancy. Similar to recommendations for the treatment of chronic pain in non-pregnant people, providers who care for pregnant women with chronic pain are encouraged to discuss goals with the patient, including risks and benefits of continuing chronic opioid therapy in pregnancy. Some women elect to reduce or discontinue opioids for chronic pain in pregnancy due to risk for neonatal abstinence syndrome and concern about safety in breastfeeding. For some women, the functional benefit of continuing chronic opioid therapy must be considered. Whether the decision is made to continue chronic opioid therapy, strategies to increase alternative pain therapies should be implemented: exercise, physical therapy and nonopioid pharmacotherapies.
If a woman is screened and there is concern of clear evidence for opioid use disorder, a referral to treatment should not be delayed and should be independent of a woman’s decision to continue the pregnancy. Addiction treatment specialists can then assist a woman in making treatment decisions that are right for her, and meet her level of severity of disease. Medication-assisted treatment with methadone or buprenorphine is considered standard of care. For patients who live in areas with limited or no access to specialty addiction care, referral should be made to a qualified provider who can address the substance use issues. A local data-waived physician may have these qualifications. Physicians engaged in the care of obstetric patients are strongly encouraged to obtain a DATA 2000 waiver and partner with their local community mental health centers to deliver the mental health services so critical to this population. Detoxification alone has been demonstrated to result in unacceptably high rates of relapse, overdose and death when compared to MAT[5-6]. Naltrexone has not been studied enough at this time for use in pregnancy. Providers should also provide naloxone overdose reversal kits to pregnant women; although severe precipitated withdrawal could contribute to fetal distress, naloxone should never be withheld in the event of maternal overdose, and should be used to potentially save the woman’s life.
A note about CPS
Colorado is a state where reporting to Child Protective Services (CPS) for substance use during pregnancy is not mandatory for a person with no other children in the home. Mandatory reporting is required when the pregnant person has other children in the home whose safety may be compromised because of ongoing drug use. Likewise, a positive urine drug screen at the time of delivery in the hospital will likely trigger a duty to report by the hospital staff. Notably, the pregnant person who is compliant with treatment and is otherwise stable does not require reporting. CRS 13-25-136 protects pregnant persons from being criminally penalized by the results of drug and alcohol screenings obtained during prenatal care, though this may not protect them if they are involved in abuse/neglect proceedings. It goes without saying that many pregnant persons may be concerned about the potential for communication with and involvement by government entities that could result in separation from their children.
The physician’s role here is clear, with supportive documentation where possible and early and direct communication as needed. When reporting is required, the CPS team would benefit from understanding the level of substance use, willingness to engage in treatment and compliance with the current treatment regimen. If a woman is already involved with CPS, communicating her engagement in treatment to her case manager may be of value to the patient and to the CPS team.
Labor and delivery
The labor and delivery team will benefit from awareness of the patient’s involvement in treatment. She will receive the best care possible when all team members are aware of her treatment plan. Communication with anesthesia and the labor and delivery team in developing the plan of care for pain management is critical. While maintenance on buprenorphine or methadone during labor and delivery is reasonable, the plan for pain management needs to be individualized. Setting clear expectations and providing reassurance that your patient’s pain will be managed appropriately with proactive planning is of great importance to her. A meeting with the anesthesiologist prior to delivery would be ideal.
Methadone and buprenorphine are both safe in breastfeeding. Women who have no other contraindication to breastfeeding, such as HIV positive or ongoing substance use, should be supported and encouraged to breastfeed. Even though methadone and buprenorphine may cause Neonatal Abstinence Symptoms in the newborn, NAS is an expected, temporary and treatable condition that at this time does not appear to have any longer-term effects on the child’s future growth and development. The possibility of NAS occurring is not a reason to avoid providing medication-assisted treatment to pregnant and mothering women.
As our understanding of opioid dependence and its attendant treatment evolves, so must the care of vulnerable populations who present with this diagnosis. We now know that opioid replacement therapy in pregnancy is safe and can be highly effective in fostering maternal recovery, healthy parenting and re-establishing the family unit.
1. Wright TE, et al. The role of screening, brief intervention, and referral to treatment in the perinatal period. American Journal of Obstetrics and Gynecology. 2016; 11: 539-547.
2. American College of Obstetricians and Gynecologists. Opioid Use and Opioid Use Disorder in Pregnancy. ACOG Committee Opinion no. 711. Obstet Gynecol 2017; 130:e81-94.
3. Desai RJ, Hernandez-Diaz S, Bateman BT, Huybrechts KF. Increase in prescription opiid use during pregnancy among Medicaid-enrolled women. Obstet gynecol 2014;123:997-1002.
4. Center for Substance Abuse Treatment. Medication-assisted treatment for opioid addiction during pregnancy. In: Medication addicted treatment for opioid addiction in opioid treatment programs. Treatment Improvement Protocol (TIP) Series, No. 43. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2005. P211-24.
5. Jones HE, Terplan M, Meyer M. Medically assisted withdrawal (detoxification): Considering the mother-infant dyad. J Addic med 2017; 11:90-2.
6. Saia KA, Schiff D, Wachman EM, Mehta P, Vilkins A, Sia M, et al. Caring for pregnant women with opioid use disorder in the USA: Expanding and improving treatment. Curr Obstet Gynecol rep 2016;5:257-63.
7. Jones HE, et al. Treatment of Opioid Dependent Pregnant Women: Clinical and Research Issues. J Subst Abuse Treat 2008;35:245–59
Posted in: Colorado Medicine | Initiatives | Prescription Drug Abuse