The Smart Patient's Guide to
Chronic Pain Management

Pregnancy, Pain Management, and Medication: A User’s Guide

What to do when you’re on opioids/painkillers and considering a pregnancy, or just found out you are pregnant.

 

For years, Jamie Peguero, a mom of two from San Bernardino, California, had suffered from chronic intractable pain, including chronic myofascial pain and dysfunction (CMPD) and fibromyalgia. She was prescribed a variety of medications, including hydrocodone, an opioid, and gabapentin, an anticonvulsant, that helped her manage the pain. While pregnant with her first daughter, she was able to stay on some of her medications while discontinuing others. Nia, now 7, was born healthy.

Image provided by Jamie PegueroPeguero shares her experience with managing intractable pain and pregnancy.

“But the pain became more out of control after the birth of Nia, so I started on long-acting fentanyl along with hydromorphone and morphine sulfate,” Peguero says. All three of the new medications she was taking were opioid-based. “I stayed on the medications during my second pregnancy because if I hadn’t, my pain would have been a 10 (out of 1 to 10 pain rating scale) and I would have been in the ER,” Peguero says. Without her medication, Peguero says her pain would grow out of control, often leading her to experience suicidal thoughts, and she thought the intractable pain could increase her risk of stroke or heart attack. (Editor’s Note: Some research has suggested links between chronic pain and increased risk for cardiovascular disease, especially when stress and depression are factors.)

After multiple discussions with her doctor, they agreed to let her stay on the opioid-based medications and stayed in close contact with her throughout the pregnancy. They also encouraged her to try acupuncture, massage, and hydrotherapy as non-opioid alternatives, but says Peguero, they were simply not enough to control the pain. In fact, she was bed-bound for most of the pregnancy due to pain and exhaustion. “I was trying to manage everything and just stay functioning at a basic level,” she recalls. Her second daughter, Maya, was born in August 2018, with neonatal abstinence syndrome (NAS).

Understanding Neonatal Abstinence Syndrome (NAS)

Neonatal abstinence syndrome occurs when a newborn withdraws from drugs, specifically narcotics, that he or she was exposed to in the womb. An infant who experiences withdrawal symptoms from an opioid the mother was taking may display excessive sucking, irritability, poor feeding, sleep problems, slow weight gain, trembling, vomiting, and rapid breathing.

NAS is on the rise in the US. Between 2000 and 2012, there was a five-fold increase in the proportion of infants born with the syndrome. In 2012, nearly 22,000 babies were born with NAS – which means a baby suffering from opiate withdrawal is born every 25 minutes.

Maya remained in the hospital for three weeks while doctors monitored her condition. Now about 4 months old, she is pretty healthy, but still has occasional feeding problems, says Peguero. “Part of me feels guilty for what the baby had to go through, but I did what I had to do for myself and for her,” says Peguero. “My doctor told me that if I was in tremendous pain and under a lot of stress, this would be bad for the baby.”  

Source: 123RFDiscuss your medication plan with your doctor as soon as you begin to plan a pregnancy or find out you are pregnant.

Controlled Medications Can Remain an Option

Peguero’s case is not uncommon. While many women choose to go off opioids or other controlled substances, such as benzodiazepines or antidepressants, once they become pregnant or start thinking about a pregnancy, many women with intractable pain like Peguero stay on them in order to survive. In fact, women who suffer from chronic pain conditions and who are on opioid therapy or other controlled substances can still become pregnant and deliver a healthy baby.

Your doctor may, however, recommend lowering your dose through a tapering plan. Tapering involves slowly reducing how much medication you take over a period of weeks or months, and may involve adding other, less dangerous, or less addictive medications to your treatment plan. Abruptly discontinuing opioids during pregnancy is not recommended, explains Clara Ward, MD, a maternal-fetal medicine physician with the McGovern Medical School at UT Health/UT Physicians in Houston, as you could experience withdrawal. Talk to your doctor about opioid replacement therapy and how to best manage potential withdrawal symptoms. If your doctor continues to prescribe opioid treatment, “the lowest dose for the shortest duration” is advised, she adds.

If you are on benzodiazepines, avoid stopping your doses cold turkey as that can be dangerous as well, says Yili Huang, DO, director of the Pain Management Center at Northwell Health’s Phelps Hospital in Sleepy Hollow, NY. “This can cause seizures, which can lead to death,” he says. Work with your doctor to figure out which medications you can safely stay on and which you should be tapering off.

Remember, “Fear of misuse or fetal effects should not deter physicians from treating pain in pregnancy with opioids, when appropriate,” says Dr. Ward.

Adds Rebecca Starck, MD, an obstetrician/gynecologist at the Cleveland Clinic, patients who are taking medication for chronic pain won’t necessarily be told they can’t take their medications any longer. “[They] may be encouraged to transition to an alternative treatment option,” she says. “It’s a very individual decision.”

What Are the Alternatives?

The first line of therapy for pain during pregnancy is acetaminophen, says Dr. Ward, but other medications might be recommended by your doctor depending on the type and severity of pain. “For all therapies, a discussion of risks and benefits is essential,” she says.

Interventional treatments

There are also several interventional pain management techniques available, such as nerve blocks, that can help to provide temporary pain relief. Nerve blocks involve injecting strong analgesic medications like opioids or steroids directly into the affected nerves to relieve pain. One common injection is called an epidural steroid injection (ESI), which a doctor may recommend for lower back pain (Editor’s Note: Injections of corticosterioids into the spinal space are considered off-label by the FDA due to potential safety risks). Facet joint injections, single nerve root blocks, and sacroiliac joint injections are other options.

Injections can help patients to avoid some of the side effects associated with taking oral dosages of medications, explains Dr. Huang, and may be used to help with specific chronic pain conditions such as migraine or back pain.

Behavioral and alternative therapies, which range from acupuncture and massage to psychotherapy, may also help you to reduce pain levels during a pregnancy.

Keep the Communication Lines with Your Clinician Open

All too often, women with chronic diseases don’t bring up the subject of pregnancy with their doctor. In fact, a global survey of women living with chronic medical conditions, such as rheumatoid and psoriatic arthritis, found that 44% of surveyed women in the US had concerns serious enough to cause them to delay their plans to get pregnant, and 36% decided to discontinue their treatment while planning their pregnancy or at the start of their pregnancy. The survey, conducted by the Autoimmune Motherhood Movement in connection with the biopharmaceutical company UCB, also found that only 41% of respondents consulted a healthcare professional before getting pregnant. The survey included at 1,052 women in the US, major European nations, and Japan of childbearing age (18 to 45) with chronic inflammatory disease diagnoses.

Whether you are considering a pregnancy or just found out you are pregnant, if you are on controlled medications (see a list of examples here, https://www.dea.gov/drug-scheduling), it’s crucial to have a conversation about your treatment options with your doctor as soon as possible. Your doctor can share insights into the impact your pregnancy may have on your condition as well as any risks associated with continuing medications. You can also work to set goals together for optimizing your health in anticipation of the pregnancy, which may decrease your risk of any complications, says Dr. Ward. Optimizing health prior to pregnancy when possible is always recommended, she adds, as “being in good physical shape can result in less pain during pregnancy.”

Of course, how you manage pain during pregnancy will depend upon the type of pain you have, she says. “When the pain is due to an underlying medical condition, such as lupus or rheumatoid arthritis, using medications that specifically improve the control of that condition is preferable and may reduce the amount of other medications needed, such as opioids,” she explains. 

What about Breastfeeding While on Opioids?

Most medications taken by the mother are excreted into breast milk, so ideally, a mother would avoid narcotic pain medications altogether while nursing, says Dr. Starck. However, she adds that limited opioid use is “not a contraindication for breastfeeding. We still encourage our patients to breastfeed, however, we would recommend limiting it to the minimal amount necessary.”

Adds Dr. Ward, “For most women, the benefits of breastfeeding outweigh the risk of opioids,” and if the mother breastfeeds prior to taking the medication, that can limit the amount transferred to the baby. Short-term use of opioids taken as prescribed is rarely harmful to newborns, according to Dr. Ward. However, she encourages women who want to breastfeed while taking opioids to discuss this with their doctor in advance as some forms of opioids may have more risks for the infant than others. Regardless of the medication choice, monitoring for excess sleepiness of both mom and baby is advised, she says.

For more information about taking medications during pregnancy, visit www.mothertobaby.org. The nonprofit offers a variety of helpful resources, including fact sheets on a number of medications, in both English and Spanish.

 

Updated on: 12/10/18
SHOW MAIN MENU
SHOW SUB MENU