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13 Articles in Volume 18, Issue #9
Children, Opioids, and Pain: The Stats & Clinical Guidelines
How to Fit into a New Practice
How to Talk to Your Chronic Pain Patients
How to Treat Opioid Use Disorder in Pregnant Women
Intranasal Ketamine for Acute Pain in Children
Medication Selection for Comorbid Pain Management (Part 3)
MR Neurography: Using Peripheral Nerve Imaging as a Pain Diagnostic
Naloxone in Schools; Buprenorphine Conversions; OUD Management
Opioid Conversion Calculations and Changes
Pes Anserine Tendino-Bursitis as Primary Cause of Knee Pain in Overweight Women
Self-Management of Chronic Pain in Primary Care
The Homebound Adolescent: Managing Chronic Pain Conditions in the Pediatric Population
The Opioid Band-Aid: The State of Pain Pills, Congressional Bills, and Healthcare in the US

How to Treat Opioid Use Disorder in Pregnant Women

Plus: Best practices for monitoring and caring for female patients with chronic pain conditions.
Pages 29-33
Page 1 of 3

With Theresa Mallick-Searle, RN-BC, ANP-BC and Courtney Kominek, PharmD, BSPS, CPE

Rates of opioid use disorder (OUD) in pregnant women quadrupled between 1999 and 2014, according to a CDC Morbidity and Mortality Weekly Report.1 Exposure to opioids by pregnant women increases the risk of maternal and neonatal complications, including potential adverse outcomes such as preterm labor, stillbirth, neonatal abstinence syndrome, and maternal mortality.2,3 “This report identifies a significant public health issue,” Theresa Mallick-Searle, RN-BC, ANP-BC, from the division of pain medicine at Stanford Health Care in Redwood City, CA, told PPM. “It [also] highlights the importance of screening, monitoring, and management of opioid use disorder during pregnancy.”

What’s Behind the Increase

Sarah C. Haight, MPH, and colleagues at the CDC analyzed1 hospital discharge data collected between 1999 and 2014 from the Healthcare Cost and Utilization Project (HCUP). This data documented the presence of OUD in obstetric patients at in-hospital deliveries.

To identify OUD, researchers applied criteria from the International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9 CM) and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). Data was available from a total of 30 states, plus Washington, DC. Only 14 states were analyzed during 1999, whereas 28 states were analyzed during 2014.

According to the analysis, national prevalence of OUD increased by 333%. In 1999, 1.5 cases of OUD per 1,000 in-hospital deliveries were documented, as compared to 6.5 per 1000 in 2014. The national average annual rate of increase was 0.4 cases per 1,000 in-hospital deliveries per year. Statewide analyses revealed OUD prevalence ranging from 0.7 in Washington, DC to 48.6 in Vermont during 1999. By 2014, more than 30 cases per 1,000 in-hospital deliveries were documented in states such as Vermont and West Virginia.

Average annual rates increased linearly across all states over the span of the study. California reflected the lowest increase in annual rate, whereas Maine, New Mexico, Vermont, and West Virginia had the highest increases in average annual rates. These rates ranged from 2.5 to 5.4 cases per 1,000 in-hospital deliveries per year. Regarding this difference in data, the CDC authors noted that diagnostic procedures were not uniform across states. Furthermore, trends of increased average annual rates may have resulted in part from better screening and diagnostic practices over time, rather than a higher prevalence of OUD.

“The first multistate analysis of opioid use disorder among delivery hospitalizations can be used by states to monitor the prevalence of opioid use disorder at delivery hospitalizations,” the authors wrote. “There is [a] continued need for national, state, and provider efforts to prevent, monitor, and treat opioid use disorder among reproductive-aged and pregnant women.”

Women should be properly screened in the prenatal phase.Women should be properly screened in the prenatal phase (Source: 123RF).

Monitoring Opioids During Pregnancy

Both the CDC and American College of Obstetricians and Gynecologists (ACOG) have released guidelines4,5 addressing opioid use during pregnancy. Both organizations recommend that clinicians only prescribe opioids when necessary, and counseling of risks versus benefits should always take place. Furthermore, clinicians are reminded to always review data from the Prescription Drug Monitoring Program prior to prescribing opioids. Contraception counseling prior to pregnancy is also encouraged; ACOG, in particular, additionally recommends universal substance use screening, including for opioids, during the first prenatal visit.

“We need to do more to identify and treat opioid use disorder. This includes having more resources available for treatment,” said Courtney Kominek, PharmD, BSPS, CPE, a pain management specialist at Harry S. Truman Memorial Veterans’ Hospital in Columbia, MO. “This is difficult to deliver since many pregnant women with opioid use disorder may not present for prenatal care or other preventative healthcare due to concerns with stigma or legal consequences including child custody.” Mallick-Searle also weighed in, stating, “This is a real issue when much scrutiny and possible legal sanctions may be directed toward the use of opioids during pregnancy. Women with a need to use opioids during pregnancy for pre-existing or worsening chronic pain, who are not differentiated from those with a diagnosis of opioid use disorder, may forego the use of a legitimate sanctioned treatment strategy that can result in additional pain, suffering, and possible poor maternal and fetal outcomes.”

Based on her clinical experience, Mallick-Searle suggested a number of actions that may be taken to improve the care of pregnant women. She recommends, for instance, assessing patients’ living environments for risk-taking behaviors, partner abuse, co-dependency, and available resources. She also suggests improving clinical education surrounding multidisciplinary pain management, as well as using beneficial medication-assisted therapy.

Dr. Kominek added that universal screening of substance use should not just be used for pregnant women, but for women of childbearing age as well. “Opioid use disorder does not discriminate, and that includes pregnant women,” she said. With the study data here ending in 2014, Dr. Kominek believes that with underreporting common amongst the literature, the rates of opioid use disorder among pregnant women may “be even worse now.”

 

....

 

More Best Practices: When Your Pain Patient is Pregnant with OUD 

A Q&A with Laurie L. Meschke, PhD

An associate professor of public health at the University of Tennessee, Knoxville, Laurie L. Meschke, PhD, recently published contraception survey results showing that a majority of women (n = 287, 81% response rate) enrolled in medication assisted treatment (MAT) for opioid use disorder (OUD) at two Tennessee-based MAT clinics had been: sexually active in the past 12 months (88%) and pregnant at least once (98%). In addition, a large percentage of these women reported being uninsured (42%). PPM followed up with Dr. Meschke to talk about the importance of this research and her recommendations for managing OUD in pregnant women.

PPM: In today’s opioid-focused climate, why is there a need to understand more about females undergoing MAT?

Last updated on: December 3, 2018
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Managing Opioid Use Disorders and Chronic Pain
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