The rate of opioid use disorder (OUD) among pregnant women more than quadrupled from 1999 to 2014.1 Since the rate of opioid overdose has skyrocketed in recent years, treating pregnant women with OUD calls for a well-informed approach to patient safety—and an understanding of how pregnancy presents a unique opportunity for treatment.
During pregnancy, opioid use presents distinct risks—but pregnancy can be a turning point for women experiencing OUD. Though it is a stressful time, it can also be a time of motivation to change. When treating pregnant women and their infants, physicians should consider the following six essential steps:
- Screen all pregnant women for substance use disorder with the four Ps: Ask patients about drug use by their Parents, Partner, in their own Past pregnancies, and in this Pregnancy. The American College of Obstetricians and Gynecologists (ACOG) recommends universal screening for alcohol, tobacco, and drugs.2
- Recommend medication addiction treatment for women who have OUD: Medications improve maternal and fetal outcomes substantially over medication-free treatment.3 Buprenorphine and methadone are the only FDA-approved treatments for OUD in pregnancy.
- Encourage women who are stable on medication addiction treatment for OUD to continue to breastfeed: For women on buprenorphine or methadone and not using illicit drugs, breastfeeding is strongly recommended.
- Use eat-sleep-console for neonatal abstinence syndrome (NAS): Instead of the Finnegan scale, use eat-sleep-console, and keep mother and baby together if possible.4
- Prescribe naloxone for three categories of patients: (a) those with OUD, (b) those with chronic opioid prescriptions, and (c) those with suspected illicit use of other drugs, including stimulants.
- Provide postpartum care: Many resources disappear just as patients are facing sleep deprivation, stress, and, in some cases, postpartum depression. Educate patients regarding the risks of relapse, reduce harms with naloxone prescriptions, and continue both medication-based and nonmedication treatments. Encourage patients to establish care with a primary care physician who can continue to care for them.
These six essential steps are derived from the following Opioids Stewardship Checklist, which offers a set of general principles for patient safety with opioids.
Opioids Stewardship Checklist
- Manage pain safely.
- Prevent new opioid starts.
- Treat opioid use disorders.
- Stop overdose deaths.
To prevent new opioid starts, the CDC has issued a set of guidelines:
To manage pain safely and prevent opioid starts, physicians should consider the Enhanced Recovery After Surgery bundle,5 which includes the routine use of nonsedating pain treatments such as nonopioid drugs and regional anesthesia. Postoperative pain management using an ERAS protocol was studied in patients with open gynecological surgery and was found to reduce mean opioid consumption by 72 percent without differences in pain scores.
By keeping in mind the Opioids Stewardship Checklist and following the six essential steps when treating pregnant or parenting mothers suffering from OUD, physicians can move from stigma to science, improving outcomes for mothers and infants.
Hannah Snyder, MD, practices primary care and addiction medicine at Zuckerberg San Francisco General Hospital, is a clinical assistant professor at UCSF, and is the director of Project SHOUT (Support for Hospital Opioid Use Treatment).Christine Pecci, MD, practices family medicine at Zuckerberg San Francisco General Hospital and is a clinical professor with UCSF. These opinions are of the authors and not associated with any of these organizations.