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14 Articles in Volume 18, Issue #9
Assessing Arthralgia in Children
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

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?

Dr. Meschke: In the US, 45% of pregnancies are unplanned. This figure far exceeds that of other nations.1,2 Unplanned pregnancies are even more common for women with OUD; 75 to 80% have reported an unplanned pregnancy.3-5 Family planning decision-making provides an opportunity to empower women, including those diagnosed with OUD.6 However, socio-economic challenges, such as being uninsured or relying on public insurance, can restrict the type or duration of contraception access.7

OUD can also further complicate pregnancy outcomes and childrearing. Infants who are exposed to opioids during pregnancy may experience opioid withdrawal symptoms or neonatal abstinence syndrome (NAS). Medication-assisted treatment (MAT) for OUD includes a daily dose of prescription medication that prevents or reduces withdrawal symptoms related to prolonged opioid use. Although MAT helps to reduce the risk of withdrawal and decreases the risk of relapse, for women, the medications have also been related to increased risk of infants developing NAS. In 2017, just under 70% of the babies born with NAS in Tennessee, for example, had been exposed during the pregnancy to MAT prescribed opioids. Infants who are exposed to opioids in utero are at greater risk of experiencing withdrawal symptoms that require treatment and longer hospitalization. This treatment results in increased costs, particularly to the state, as the majority of women who have babies with NAS are uninsured or on public insurance.

The long-term social and economic implications of NAS are not well understood. For example, parental drug use was associated with half of the children taken into custody by the Tennessee Department of Children’s Services.8 In general, it is important to note that the profile of women undergoing MAT reflects a constellation of challenges beyond insurance status, such as housing concerns, histories of nonconsensual sex, tobacco use, low education, unplanned pregnancy, and low knowledge about contraception. These challenges support the need for holistic or wrap-around services to support recovery.

PPM: What core points should clinicians share with women who are on chronic opioid therapy and also anticipating a pregnancy?

Dr. Meschke: Chronic pain medication, such as opioids, can be highly addictive. Opioid use during pregnancy — including MAT – promotes the risk of giving birth to an infant with NAS. Prenatal use of other substances in addition to opioids, such as tobacco, may also increase the severity of NAS.9 Non-opioid pain medication during pregnancy may increase the risk of neonatal withdrawal syndrome.

If pregnancy is anticipated and a woman is using but not misusing or abusing her chronic pain medication, ideally her physician and/or treatment team would assist in identifying an alternative treatment for her pain prior to conception. If the woman is suffering from OUD, MAT remains the recommended standard of care for pregnant women with OUD by the American College of Obstetrics and Gynecology, the World Health Organization, the US Substance Abuse and Mental Health Services Administration (SAMSHA),10-12 and the American Society of Addiction Medicine. In general, these guidelines encourage pregnant women with OUD to initiate or continue MAT.

Given the relation between prenatal opioid use and NAS, it is also important for women to be aware of state and local laws, which may criminalize opioid use during pregnancy. For example, Tennessee recently ended Public Chapter 820, a law that prosecuted women for illegal narcotic use if their child was born dependent on a narcotic or demonstrably harmed by illegal prenatal narcotic use.13 Such laws that target marginalized and vulnerable women have been deemed inhumane and discriminatory by organizations such as Amnesty International.14,15

PPM: If a patient with an OUD becomes pregnant, what might a plan of action be?

Dr. Meschke: SAMHSA has released the most recent recommendations related to OUD and pregnancy.12 These evidence-based guidelines are grounded in an extensive literature review conducted by a panel of experts. As noted, MAT is the recommended approach for pregnant women with OUD. SAMHSA emphasizes the importance of compassionate, individualized care for women using opioids during pregnancy.

Given the increased risk of relapse, opioid withdrawal during pregnancy, even if supervised by a medical professional, is not recommended by SAMHSA.12 Nonetheless, a limited but growing number of medical professionals and researchers are reconsidering detoxification during pregnancy.16

A 2016 study of 310 pregnant women with OUD in East Tennessee revealed that detoxification during pregnancy, including acute, involuntary detoxification related to incarceration, resulted in no adverse fetal outcomes.17 Bell and his colleagues17 cited five additional studies assessing detoxification during pregnancy. Of the 477 patients included across these five studies, no adverse fetal outcomes occurred with the exception of one spontaneous abortion that occurred in the first trimester.18 Whether a woman choses to initiate or maintain MAT during pregnancy or to detoxify, her decision should be undertaken with the support of qualified medical and behavioral health professionals.

What best practices can clinicians take to treat this population? (Source: 123RF)

PPM: If a patient is undergoing MAT for OUD, what key considerations should be kept in mind regarding potential pregnancy?

Dr. Meschke: The risk of unintended pregnancy among women for MAT is exceptionally high. Of the women in our study, 76.7% reported an unintended pregnancy with 40.9% of these women doing so while on birth control. They identified the involvement of primarily user-dependent methods (eg, birth control pill or condom).19 These figures, along with the increased risk of giving birth to an infant with NAS, support the use of a long-acting, reversible contraception (LARC) for women using opioids, whether prescribed, MAT, or active misuse or abuse. LARCs include injections (eg, Depo-Provera), intra-uterine devices (IUDs), and subdermal implants (eg, Nexplanon). LARCs have been recommended as an effective strategy to decrease unplanned pregnancies.20 Women who are currently using opioids have also indicated a preference for LARC use.21

PPM: What can healthcare providers do better to aid female patients on chronic opioid therapy?

Dr. Meschke: The SBIRT (Screening, Brief Intervention, and Referral to Treatment) tool provides an excellent OUD identification and assistance strategy for healthcare providers. First, providers should proactively screen all women of childbearing age for substance use disorders, including OUD. If a concern is identified, the practitioner then initiates a short conversation about SUD or OUD, providing guidance and answering questions. If the patient is a candidate for additional treatment, the practitioner then provides this information. To be effective, this brief but important interaction requires practitioner preparation, intention, and training. Strategies to promote SBIRT program practices include its integration into the electronic medical record, relationships with OUD and SUD referrals, and the identification of a practice champion to manage and encourage adherence to the implementation of SBIRT.22

Data show that women are more likely to have co-occurring mental health and substance use disorders than men,23 and yet, interventions and services have been historically developed and tailored to the concerns of men.24,25 At the same time, women receiving MAT have greater functional impairments, leading to problems with maintaining employment, housing, relationships, and personal care, for example, than men.26 SAMHSA recently issued guidance27 on the types of services that should be included in comprehensive MAT programs for women, including:

  • special groups to address challenges faced by opioid-addicted pregnant women, education and discussion groups on parenting and childcare
  • available treatments for women addicted to opioids, including pharmacotherapies
  • education and discussion groups on parenting and childcare
  • special groups and services for children and other family members
  • couples counseling
  • assistance in locating safe, affordable housing.

PPM: What is your take on SAMHSA’s proposal? What more may be needed?

Dr. Meschke: I respect and support the SAMHSA’s evidence-based recommendations. They emphasize women’s roles as parents and partners and also address the possibility that her partner may also have OUD. However, reproductive health is missing on this list. Based on our cross-sectional study at the University of Tennesse,19 having more knowledge about opioid use and reproductive health presents an opportunity to reduce unplanned pregnancies and, hence, avoid additional stressors that may contribute to relapse.

Specifically, we found that women enrolled in MAT who were not currently using contraception were less likely to know that it was important to avoid pregnancy and that pregnant women should not use painkillers, than women in MAT who were using effective contraception or who had experienced bilateral tubal ligation or surgical sterilization. A more recent SAMHSA document does highlight the importance of post-partum contraception use for women with OUD,12 but contraception is an important topic for all women of childbearing age, regardless of current or recent pregnancy.

- Q&A by Angie Drakulich, PPM Managing Editor

Last updated on: April 12, 2019
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Managing Opioid Use Disorders and Chronic Pain
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