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    The opioid crisis: Prenatal and postnatal care

    Recent data support treating opioid use in pregnant patients with MAT

     

    Diagnosing and treating OUD in pregnancy

    Clinical colleagues in psychiatry have given us a new definition, framework and context for assessment of OUD with the publication of the Diagnostics and Statistical Manual 5 (DSM-5) in 2013.10 The longstanding model and language of substance abuse and dependence have been largely replaced by a single disorder along a continuum of mild to severe. The current language used to describe a substance problem was updated to reflect changing patterns of abuse. Criteria were changed to better account for cultural and socioeconomic effects on populations (Table 1).

    Treatment for OUD in pregnancy must include a multifaceted, comprehensive approach as behavioral interventions, psychosocial support and medication administration have been shown to improve maternal and neonatal outcomes.11 Pharmacotherapy for treatment of OUD (referred to as medication-assisted therapy [MAT]) has been utilized in pregnancy since the 1970s.4,12 Initially this was achieved with methadone and later with buprenorphine-based products. The benefits of MAT use in pregnancy stem from avoidance of symptomatic withdrawal. When cyclic use and withdrawal from illicitly obtained opioids is controlled, patients have the opportunity to establish and maintain medical and prenatal care and to address comorbid conditions. This reduction in medical and social risks associated with substance use in pregnancy leads to improved social, obstetric, and neonatal outcomes.13

    While a review of behavioral interventions is beyond the scope of this article, we will review currently available pharmacotherapies for pregnant women with OUD, and briefly discuss accumulated evidence regarding Medication-Assisted Withdrawal (MAW).  

    Methadone. Methadone is a full agonist of the µ-opioid receptor and has been utilized since the 1970s as the standard treatment for OUD in pregnancy.5 It is dispensed on a daily basis by registered comprehensive addiction treatment programs. Currently, it is not legal for physicians outside of such licensed treatment facilities to prescribe methadone to treat OUD (although the drug can be prescribed on an inpatient basis for continuation or initiation of MAT). All providers should be aware that potential significant medication interactions exist with methadone – including, but not limited to, some nucleoside reverse transcriptase inhibitors and non-nucleoside reverse transcriptase inhibitors, antiretroviral medications, protease inhibitors, tricyclic antidepressants or rifampin. In addition, there is a risk of maternal respiratory depression and QTc prolongation. 

    Some data suggest that physiologic changes in pregnancy may require dose adjustments.14 This is not universal, however, and should be based on evidence of withdrawal rather than provided reflexively. Other studies have supported the use of split dosing with methadone to reduce maternal symptoms of withdrawal.15

    Buprenorphine. Buprenorphine is a partial agonist of the µ-opioid receptor, thereby giving it an improved safety profile. It decreases the activity of full opioid agonists (e.g., methadone, heroin, morphine, oxycodone). Accumulated recent evidence supports use of buprenorphine in pregnancy16 and it is available as either a mono-product (buprenorphine alone, Subutex) or as a combined product with naloxone (buprenorphine/naloxone, [e.g., Suboxone). The naloxone component is not active if taken in the proper fashion (sublingually); however, a patient will experience significant withdrawal symptoms if she injects the medication (naloxone is an opioid antagonist that will displace opioids from receptors). For that reason, the combined product is used to prevent improper intravenous use of the buprenorphine. Historically, providers have had concerns about providing the combined product in pregnancy; however, accumulating data support use of buprenorphine/naloxone in pregnancy.17,18 In our own OUD in pregnancy program, we utilize the combined product. 

    Buprenorphine can be prescribed by specially licensed physicians in private office settings. Currently available evidence suggests that, while the absolute risk of developing NAS remains the same (approximately 50% of infants), those infants exposed prenatally to buprenorphine (rather than methadone) will experience NAS that is shorter and easier to treat.16 No long-term neurodevelopmental outcome data are yet available. Providers should be aware that buprenorphine is rarely associated with hepatotoxicity and that concurrent use of benzodiazepines (or other sedatives such as alcohol) significantly increases risk of overdose.19 It should be noted that polysubstance abuse is extremely common. As such, providers should be aware of the potential need for concurrent evaluation and treatment for other substance use disorders. 

    Providers interested in learning more about buprenorphine licensing are encouraged to visit https://www.samhsa.gov/medication-assisted-treatment/buprenorphine-waiver-management

    For a comparison of methadone vs buprenorphine, see Table 2. 

    Next: Medication assisted withdrawal (MAW)

    Agatha S. Critchfield, MD
    Dr. Critchfield is Assistant Professor of Obstetrics and Gynecology, University of Kentucky College of Medicine, Lexington.
    Wendy F. Hansen, MD
    Dr. Hansen is Professor and John W. Greene, Jr., MD Chair, Department of Obstetrics and Gynecology, University of Kentucky College of ...

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