Evaluation and Management of Opioid Dependence in Pregnancy

Abstract

Background Opioid use disorders are a growing public health problem in the United States. Most women who are opioid dependent are of childbearing age and management of opioid dependence during pregnancy poses unique challenges. Assessment includes evaluation for addiction, withdrawal syndromes, and co-morbid psychiatric diagnoses. Consultation-liaison psychiatrists may also be involved in acute pain management, perinatal medication management, buprenorphine induction and stabilization. For the past four decades, the standard of care has included methadone maintenance, but the increasing use of buprenorphine creates new treatment issues and opportunities. Objective To educate consultation-liaison psychiatrists in emergency and obstetrical settings about the appropriate approach toward the evaluation and basic management of women with opioid dependence in pregnancy. Method The authors reviewed the consensus literature and all new treatment options on opioid dependence during pregnancy. Discussion In this review, the authors summarize known and emerging management strategies for opioid dependence in pregnancy pertinent to consultation-liaison psychiatrists.

Nurses' Perceptions of Caring for Childbearing Women who Misuse Opioids

“…Thorough physical assessments of pregnant women misusing opioids are necessary to carry out quality care and treatment throughout pregnancy and birth (Jones et al, 2008;Keegan, Parva, Finnegan, Gerson, & Belden, 2010). Knowing the truth about drug history during pregnancy also provides information necessary for the treatment of NAS in the newborn (Hayes & Brown, 2012;Park, Meltzer-Brody, & Suzuki, 2012). The sooner this information is obtained, the more likely the newborn will receive care promptly and effi ciently, improving the likelihood of better health outcomes (Hayes & Brown).…”

Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine

“…Women on a stable dosage when not pregnant may require dosage adjustments during pregnancy because of an expanded volume of distribution and progesteroneincreased cytochrome P450 metabolism of methadone. 84 These normal physiologic changes during pregnancy can result in decreased levels of methadone, particularly during the second and third trimesters. However, adjustments are needed only if the current dosage is not sufficient to prevent withdrawal symptoms or reduce cravings.…”

“…Other fetal side effects include reduced fetal activity and heart rate and fetal growth restriction. 84 The use of methadone or buprenorphine during pregnancy has not been associated with an increase in birth defects. 56 Longitudinal studies that have examined developmental outcomes have demonstrated minimal to no long-term neurodevelopmental impact, particularly when comparing opioid agonisteexposed vs nonexposed children from similar socioeconomic groups.…”

“…56 Longitudinal studies that have examined developmental outcomes have demonstrated minimal to no long-term neurodevelopmental impact, particularly when comparing opioid agonisteexposed vs nonexposed children from similar socioeconomic groups. 56,84 Naltrexone Although the FDA has approved naltrexone, an opioid antagonist, for treatment of OUD, data are insufficient to support the initiation of naltrexone therapy during pregnancy. Animal studies in rats and rabbits have associated naltrexone with early pregnancy loss, albeit at dosages significantly exceeding those that are therapeutic in humans, but these studies did not find an increased risk of associated congenital malformations.…”

Maternal Opioid Drug Use during Pregnancy and Its Impact on Perinatal Morbidity, Mortality, and the Costs of Medical Care in the United States

“…Opioid dependence in pregnancy complicates the clinical management of an already vulnerable group of patients. Dependence increases the risk of poor maternal and perinatal outcomes [ 2 – 11 ]. Women of reproductive age who use and abuse opioid drugs, both prescription and illegal, are more likely to have a lower socioeconomic status, family instability, receive inadequate prenatal care, and suffer from alcohol, tobacco, and illicit drug use [ 12 , 13 ].…”