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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
Page 2 of 3

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?

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