Opioid Use Disorder in Pregnancy

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For more on this topic, check out ACOG Committee Opinion #711

Opioid use in pregnancy

  • It is becoming more and more common, just like opioid use in general in the US population 

    • In 2007 - 22.8% of women who were enrolled in Medicaid filled an opioid prescription

    • There has also been an increase in neonatal abstinence syndrome (1.5/1000 hospital births in 1999 → 6.0/1000 births in 2013) 

    • Substance use can be a major risk factor in pregnancy-associated deaths 

What is opioid use disorder? 

  • Pattern of opioid use characterized by tolerance, craving, inability to control use, and continued use despite adverse consequences 

    • DSM-5: 11 main symptoms of opioid use disorder and defines severity of the disorder based on # of recurring symptoms experienced within 12-months 

      • 2-3 symptoms = mild, 4-5 = moderate, 6+ = severe 

  • OUD should be handled like a disease and is treatable 

  • Is it harmful in pregnancy? 

    • Most opioids have not been shown to increase the risk of birth defects in prenatal exposure 

      • There has been some association between first trimester use of codeine with some congenital abnormalities in some studies, but not in others 

    • Untreated addiction to heroin is associated with lack of prenatal care, increased risk of fetal growth restriction, placental abruption, fetal death, and preterm labor 

      • Untreated addiction is also associated with engagement in high-risk activities (ie. prostitution, criminal activities) that can expose patients to violence, STIs, etc 

    • On other thing to be aware of is the social implications - can lead to patients being arrested and losing custody of their children 

How do we identify opioid use disorder in pregnancy? 

  • Ask about it!!!

  • ACOG states to use the SBIRT method: 

    • Screening - assess for opioid use with a validated screening method 

      • One common tool is the “5-P tool” which asks about parents, peers, partners, past, and present 

        • Basically: did your parents have a problem with substance use? Do any of your friends have a problem with substance use? Does your partner have an issue ***. Have you in the past? Have you in the past month etc. 

    • Brief Intervention - engage patient showing risky behavior in a short conversation, provide feedback and advice 

    • Referral to Treatment 

  • Quick note on urine drug screens

    • These should only be done with patient consent, and should be done in compliance with your state laws 

    • Pregnant patients should also be made aware of legal ramifications of testing positive  

    • You shouldn’t do this to “penalize” your patient or “catch” your patient. 

How do we treat opioid use disorder in pregnancy? 

  • Medication-assisted therapy (MAT)

    • Usually with opioid agonist therapy like methadone or buprenorphine 

    • Reasoning: avoid withdrawal symptoms and prevent complications of nonmedical opioid use by reducing relapse risk and its associated consequences 

      • Patients that have opioid use disorders will engage in risky behaviors to obtain opioids (ie. heroin) that can sometimes be dangerous (both behaviors and the non-medical opioid

      • Also improves adherence to prenatal care and addiction treatment programs 

    • Methadone 

      • Dispensed daily by registered treatment programs/clinics 

      • Usually have a comprehensive treatment location 

      • Methadone doses may need to be adjusted throughout pregnancy to avoid withdrawal symptoms

        • May need to go to twice daily dosing  

      • Can have interactions with other medications (ie antivirals) and can prolong QTc 

    • Buprenorphine (Subutex)

      • Acts on same mu-opioid receptors as heroin and morphine, but is a partial agonist → overdose is less likely 

      • Fewer drug interactions

        • Therefore, can be treated on an outpatient basis without need for daily visits to an opioid treatment program 

      • Can also be combined with naloxone (Suboxone) to reduce diversion because if injected, will cause severe withdrawal 

    • You should not transition from methadone to buprenorphine because of significant risk of precipitated withdrawal (remember that buprenorphine is a partial agonist) 

  • What about withdrawal as therapy? 

    • Usually not recommended because it is associated with higher relapse rates (59-90%) and poorer outcomes 

      • Relapse leads to risky behavior, no prenatal care, etc. 

    • However, if patient does not accept medication, medically supervised withdrawal is an option — often requires prolonged inpatient care and intensive outpatient behavioral health follow up 

  • Behavioral therapy - also encouraged 

Considerations in antepartum/intrapartum/postpartum care 

  • Consult with NICU, anesthesia, and pain specialists 

    • Patients may require more pain medication than average, especially if recovering from C/S 

    • Also, they should be aware of neonatal abstinence syndrome and that their baby will need to stay in the NICU for a few extra days and may not be able to go home with the immediately 

      • Can be seen in 30-80% of babies born to patients taking opioids 

      • Can manifest as disturbances in GI, autonomic, and central nervous systems → irritability, crying, poor sleep, uncoordinated sucking reflexes, and poor feeding 

      • Each NICU or nursery may have their own protocols, so check with yours to see how long they tend to observe babies after birth 

    • Breastfeeding is encouraged if patients are stable on opioid agonists 

  • Continue their medication - don’t stop methadone or buprenorphine while inpatient!

  • Possible dose reduction postpartum - work closely with their methadone clinic