Opioid Use Disorder in Pregnancy
/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