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16 Articles in Volume 20, Issue #5
20/20 with Drs. Carmen R. Green and Johnathan Goree: Racial Disparities in Pain Care
A Kratom Primer: Miracle Medicine or Herb of Abuse?
A Pilot Study: Incidence and Prediction of Diversion among Opioid Therapy Patients
Analgesics of the Future: G-Protein Biased Mu-Opioid Receptor Ligands
Application Note: Decellularized Human Placenta in the Treatment of Infracalcaneal Heel Pain
Are Clinicians Effectively Counseling Patients on Safe Opioid Storage and Disposal? Survey Results
Ask the PharmD: How to Manage Pain Meds During Pregnancy?
Behavioral Medicine: Managing Anxiety and Maladaptive Behaviors
Case Report: Spinal Cord Stimulation for the Treatment of Pain Associated with Chronic Pancreatitis
Differential Diagnoses: Inflammatory or Non-inflammatory Chronic Back Pain?
Pelvic Inflammatory Disease: Diagnosis, Education, and Treatment Options
Product Review: Non-Invasive Neuromodulation for the Treatment of the Most Difficult Pain Conditions
Provider Perspective: Carpal Tunnel's Association with Hypothyroidism
Research Insights: Opioid Use During the Peripartum Period – What to Expect
Special Report: Race, Pain Management, and the System
When Patients Become Pregnant: How to Maintain Chronic Pain Management

Research Insights: Opioid Use During the Peripartum Period – What to Expect

Clinical considerations for treating pregnant pain patients on opioid therapy or diagnosed with OUD.

Maternity care is the most common reason for hospitalization in the United States. Approximately one-third of women have a cesarean delivery, and two-thirds of those receive a peripartum opioid prescription.1 For the two-thirds of women who have a vaginal birth, approximately one-quarter receive an opioid prescription. However, wide variations in data exist  across states in reported postpartum prescription rates, duration, and dose, providing opportunities to develop guidelines on postpartum opioid use, improve prescription safety, and reduce opioid-related harms among women in the postpartum period.2

The first exposure to opioids for many women follows childbirth, but overprescribing after delivery can lead to increased opioid availability and, thus, diversion in the community. In one study, women with vaginal deliveries received an average of 10 opioid pills that remained unused; those with cesarean sections received an average of 7.5 unused pills. Of 37 women in the study, only two disposed of their unused opioid pills,3 a rate that is consistent with inpatient care in general.4

This rate may be improved by increasing patient education regarding storage and disposal of opioids, according to Gerardo Arwi, MD, of the University of Western Australia Medical School. In addition, “evidence-based hospital guidelines and public health policies are needed to improve opioid stewardship.”4

The first exposure to opioids for many women follows childbirth, but overprescribing after delivery can lead to increased opioid availability and, thus, diversion in the community. (Image: iStock)

New Persistent Opioid Use

Women undergoing childbirth are a significant population who continue to use opioids after expected surgical recovery. Alex Peahl, MD, of the department of obstetrics and gynecology at the University of Michigan, and colleagues examined national insurance claims data from 2008 to 2016 to assess the association between opioid prescribing for vaginal or cesarean delivery (defined as one or more opioid prescriptions from 1 week before delivery to 3 days after discharge) and rates of new persistent opioid use among women (defined as pharmacy claims for one or more opioid prescription 4 to 90 days after discharge and one or more prescription 91 to 365 days after discharge among women who filled peripartum opioid prescriptions).5

Of the 308,226 deliveries included in the review, peripartum opioid prescriptions were filled by 27.0% of women with vaginal deliveries and 75.7% of women with cesarean deliveries. Among them, 1.7% of those with vaginal deliveries and 2.2% with cesarean deliveries were determined to have new persistent opioid use, indicating that a substantial number of patients continue to fill opioid prescriptions long after expected recovery.5

For women with vaginal deliveries, risk factors associated with persistent opioid use included: receiving a prescription before delivery and receiving a prescription ≥225 oral morphine equivalents (MME). For women with cesarean deliveries, prescription characteristics were not associated with persistent use. Instead, patient factors including tobacco use, psychiatric diagnoses, history of substance use, and pain conditions represented the strongest risk factors.5

While ensuring that patients’ postpartum pain is a priority, the study authors point to data that opioid-sparing protocols, tailored discharge prescriptions based on inpatient use, and shared decision-making about the number of opioid tablets prescribed at discharge can be effective in reducing postpartum discharge prescribing. “Judicious opioid prescribing and preoperative risk screening may be opportunities to decrease new persistent opioid use after childbirth,” concluded Dr. Peahl.5


What about Women with Opioid Use Disorder?

The incidence of pregnant women with opioid use disorder (OUD) at delivery has quadrupled since 1999.6 Pain management of these patients during and after childbirth can be challenging because of their increased drug tolerance and hypersensitivity to pain. The American College of Obstetricians and Gynecologists (ACOG) has prepared guidelines for opioid use and OUD during pregnancy and delivery and in the postpartum period.7

According to these guidelines, women taking methadone or buprenorphine during pregnancy should continue on their maintenance dose during labor and receive additional pain relief with epidural or spinal anesthesia when appropriate. Patients should be advised of this plan in advance in order to reduce anxiety. Opioid agonist-antagonists should be avoided because they can precipitate acute withdrawal.

Patients on medication-assisted treatment (MAT) with methadone or buprenorphine will require higher doses of opioids to achieve analgesia because of tolerance to their maintenance treatment dose. In one study reported by ACOG, women who had been maintained on buprenorphine required 47% more opioid analgesia after cesarean delivery than women who did not take buprenorphine. For these women, adequate pain relief was achieved by adding short-acting opioids and anti-inflammatory agents.8

Consultation with an anesthesiologist may be beneficial to formulate an individualized pain management plan. During labor and the postpartum period, dividing the usual daily treatment dose of buprenorphine or methadone into three or four doses every 6 to 8 hours may provide partial pain relief.7 Following routine vaginal birth, postpartum pain can be controlled by alternating short-acting opioids with non-opioid NSAIDs and acetaminophen. Those taking methadone may require additional medication to maintain low pain ratings.9 Nonpharmacologic options such as massage, immersion in water during the first stage of labor, acupuncture, relaxation, and hypnotherapy may be useful adjuncts.10

Breastfeeding and MAT

Breastfeeding should be encouraged in women taking methadone or buprenorphine regardless of dose, as minimal transfer of these drugs into breastmilk occurs.11 Postpartum reductions of methadone should not be done routinely but should be titrated to the signs and symptoms of sedation; buprenorphine will most likely not have been increased during pregnancy and can be continued at the same dosage after delivery.12

Long-Term Postpartum Management and Mental Health

Women with OUD should continue their opioid agonist use postpartum, as this period represents a time of increased vulnerabilities with greater risk of relapse.13 Triggers for relapse include loss of insurance and access to treatment, demands of caring for a new baby, sleep deprivation, and threat of loss of child custody. State-specific statutes often pose punitive measures to the mother with OUD and her infant, involving the child welfare and criminal justice systems.6

As a result, screening for depression should be routine, and other mental health comorbidities should be assessed if indicated. Clinicians should make available (or refer/recommend) postpartum psychosocial support services, including substance use disorder treatment and relapse prevention programs. Patient counseling on overdose and naloxone prescribing should also be conducted.7

For long-term care, a multidisciplinary approach to women with OUD without criminal sanctions has the best chance of helping infants and families. According to ACOG, “Obstetric care providers have an ethical responsibility to their pregnant and parenting patients with substance use disorder to discourage the separation of parents from their children solely based on substance use disorder, either suspected or confirmed.”7

ACOG is a partner with other organizations in the Alliance for Innovation on Maternal Health (AIM), a national data-driven maternal safety and quality improvement initiative to improve overall maternal health outcomes. According to AIM Senior Nurse Program Manager Amy Ushry, RN, MPH, “There are 11 AIM state collaboratives that have previously or are currently implementing quality improvement work around the AIM “Obstetric Care of Women with Opioid Use Disorder" patient safety bundle. 

The AIM program convenes regular calls for these leaders to share their work, resources, and best practices. Topics discussed during calls include new toolkits and resources, educational materials for patients and families, strategies for engaging outpatient providers, best practices for improving universal screening, ideas for connecting community partners and medical providers, and developments in data collection for quality improvement.” 

More on managing medications in patients who become pregnant.

More on the ACR's reproductive health guidelines.

Last updated on: September 21, 2020
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When Patients Become Pregnant: How to Maintain Chronic Pain Management
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