Opioid use disorder during pregnancy
Nonjudgmental identification and treatment can maximize maternal/fetal outcomes
Discuss this article at currentpsychiatry.blogspot.com/2011/03/opioid-use-disorder-during-pregnancy.html
For 3 years, your mental health clinic has been treating Ms. J, age 23, for bipolar disorder. She is single, unemployed, lives alone, and receives Social Security disability assistance and financial support from her parents. She has been successfully maintained on aripiprazole, 15 mg/d, and citalopram, 20 mg/d, for 18 months. Six months ago she began to miss therapy sessions and physician visits.
Her parents inform Ms. J’s therapist that she is “snorting oxycontin” with her new boyfriend. At her next visit Ms. J confirms she has been struggling to manage an opioid use disorder for more than 1 year, and requests help.
After you educate her about the diagnosis, pathophysiology, and treatment of opioid addiction, she chooses to include pharmacotherapy as part of her treatment. After informed consent, Ms. J agrees to take buprenorphine and naloxone, meet with her therapist weekly, and attend twice-weekly Narcotics Anonymous (NA) meetings. Over the ensuing months she is gradually inducted onto buprenorphine and naloxone, 12 mg, shows improved insight and motivation, provides negative urine drug screens, and demonstrates increased ability to manage her recovery. Two weeks later Ms. J tells you she may be pregnant but wants to continue buprenorphine and naloxone.
Opioid use disorder (OUD) during pregnancy is among the most difficult clinical scenarios to manage. The prevalence of OUD during pregnancy is largely unknown. However, stigma against pregnant patients with OUD is substantial. 1 This article briefly summarizes identification, assessment, and treatment of OUD during pregnancy. To avoid confusion with the term “physical dependence, “ we will use “opioid use disorder” instead of “opioid dependence. “ The DSM-5 Substance Use Disorders Workgroup recommends combining abuse and dependence into a single disorder of graded clinical severity; however, this has not been finalized. 2
Early identification is crucial
Early identification of OUD in pregnant women can be challenging. Self-reports underestimate use 3 and shame, fear of prosecution or involvement of child welfare services, and guilt can further erode self-report. Women with OUD may have irregular menses and might not be aware of their pregnancy until several months after conception. 4 Also, women with OUD who are maintained on opioid agonist therapies may misinterpret early signs of pregnancy—such as fatigue, nausea, vomiting, headaches, and cramps—as withdrawal symptoms and may respond by increasing their opioid dosing, thus exposing their fetus to increased drug levels. Finally, many women with OUD experience amenorrhea as a result of their stressful, unhealthy lifestyle, which may preclude pregnancy despite sexual activity. When these women later enroll in an opioid maintenance program, their endocrine function may return to normal, leading to unexpected pregnancy. 5
Screening for OUD in pregnant patients has not been well studied. An interviewer’s nonjudgmental, empathic attitude may be more important than the specific questions he or she asks. It may be best to begin with less threatening questions and proceed to more specific questions after developing a therapeutic alliance. 6
Chasnoff et al 7 studied >2, 000 Medicaid-eligible pregnant patients from 9 prenatal clinics to identify risk factors for substance use during pregnancy. Alcohol or tobacco use in the month before pregnancy most differentiated current drug or alcohol use from nonuse while pregnant; however, a wide variation in use rates among patients in this study limits the generalizability of these findings. Consider OUD in women with:
- physical examination findings or history that suggests substance use or withdrawal symptoms
- positive drug test results for illicit or nonprescribed opioids
- aberrant medication-taking behaviors in those receiving prescribed opioids
- nicotine or alcohol use in the month before they knew they were pregnant
- a history of addiction-related disorders
- evidence of diseases associated with drug use, such as human immunodeficiency virus or hepatitis C
- poor prenatal care attendance
- unexplained fetal growth abnormalities.
Chasnoff et al demonstrated the reliability and effectiveness of a 1-minute, 5-item instrument (the “4 P’s Plus”) to screen for substance use, including heroin, during pregnancy ( Table 1 ) 8 In a study of 228 pregnant women, the overall internal consistency of this instrument was low but acceptable. More than three-quarters of patients (78%) were correctly classified as positive or negative, sensitivity was 87%, specificity was 76%, negative predictive validity was extremely high (97%), and positive predictive validity was low (36%). This low positive predictive validity may be acceptable in this population because over-identification of women at risk may be preferred to under-identification. The 4 P’s Plus identifies light and infrequent substance users who otherwise would go undetected, although it may place undue burden on providers to follow up on what later may be revealed to be a false positive screen. 9 OUD-specific screening approaches are lacking; screening for general substance use is discussed elsewhere in the literature. 10
A combination of interviewing and biologic drug screening may be more effective than either approach alone. 11 Drug screening should include opioids typically screened for (morphine, codeine, heroin metabolite) and those for which additional tests may be required (eg, semi-synthetics such as oxycodone and synthetics such as fentanyl). Learn your state’s civil mandates regarding drug-using pregnant women, guidelines for addiction treatment, and confidentiality provisions, especially as they relate to drug testing and mandatory reporting. Ideally, patients should be informed of these issues before they undergo drug testing or other procedures. These requirements may vary according to physician specialty or role in providing care.
Diagnosis of opioid dependence is based on DSM-IV-TR criteria; however, the proposed DSM-5 criteria for OUD may better emphasize cautions about including tolerance or withdrawal when diagnosing OUD in the setting of medically supervised and appropriate opioid use. 2
Stigma against pregnant women with OUD easily can erode therapeutic efforts. Perhaps the most important element of assessment is maximizing the therapeutic alliance to ensure that the patient complies with prenatal obstetric care and maternal addiction services. Pregnancy may be an opportune time to motivate women with OUD to make a change because they may be more open to receiving help. 12 Motivational interventions are helpful for many but not all patients; the best approach to such interventions is still uncertain. 13 Regardless of the mother’s motivation, prenatal care is fundamental.
The ‘4P’s Plus’ screen for substance use during pregnancy
Parents: Did either of your parents ever have a problem with alcohol or drugs?
Partner: Does your partner have a problem with alcohol or drugs?
Past: Have you ever drunk beer, wine, or liquor?
Pregnancy: In the month before you knew you were pregnant, how many cigarettes did you smoke?
In the month before you knew you were pregnant, how many beers/how much wine/ how much liquor did you drink?
A positive screen results when a patient answers either of the 2 questions relating to pregnancy, indicating any alcohol or tobacco use in the month before she knew she was pregnant
Source: Reference 8
OUD-specific treatment decreases opioid use and improves birth outcomes 14 ; however, retaining these patients in treatment can be difficult. Addressing social issues— including financial burdens, unstable living conditions, intimate partner violence, transportation difficulties, and limited access to medical and child care—can facilitate treatment. 5 The Addiction Severity Index version tailored to women and pregnancy 15 examines 7 domains of functioning (drugs, alcohol, psychological, social, medical, legal, and employment), informs treatment planning, quantifies treatment progress, and has predictive validity. 16 Services are more likely to be effective if started during pregnancy as opposed to after delivery. Although detoxification is possible under carefully monitored conditions, many women relapse after detoxifying, and neonatal abstinence syndrome (NAS)—a disorder in which an addicted newborn experiences drug withdrawal—is common. Therefore, the risks of detoxification often outweigh benefits. 5,17,18
Rehabilitation services for the mother can be provided at various levels of care, including outpatient, intensive outpatient, day hospital, residential, and inpatient. Although pregnancy-specific OUD treatment is ideal, it may not be available. Clinicians should attempt to locate services that can incorporate resources for pregnant women. Providing a means for child care during treatment is paramount to compliance. Develop a plan for nonconfrontational counseling, job skills training/education, and ongoing care after delivery (including child care and transportation resources) at the onset of treatment. The length of time maintained in treatment is one of the strongest predictors of abstinence. 5
Pregnant women with OUD should be screened for comorbid medical, obstetric, and psychiatric complications and referred accordingly ( Table 2 and Table 3 ). 6 Coordination among the patient’s psychiatrist, primary care provider, and obstetrician/gynecologist is essential. Programs that integrate these approaches into a single treatment team may be ideal. Although pregnancy per se may not be associated with higher risk of mental disorders, the risk of major depressive disorder may be increased during the postpartum period. 19 Young, unmarried women with recent stressful life events, complicated pregnancies, and poor overall health may face a significantly increased risk of psychiatric illness during pregnancy. 19 Patients whose opioid use has caused pregnancy complications may experience guilt and grief.
Increased education and screening for substance use as the pregnancy approaches term is necessary because patients may mistake early labor for symptoms of opioid withdrawal or worry that delivery room pain management will be inadequate and therefore relapse. Among pregnant women with addiction, preterm labor may be most common in those with OUD. 12
Medical complications common to pregnancy and substance abuse
Hepatitis (chronic and acute)
Gingivitis/poor oral hygiene
Sexually transmitted diseases
AIDS: acquired immune deficiency syndrome; HIV: human immunodeficiency virus
Source: Reference 6
Obstetric complications in women with addiction disorders
Intrauterine growth restriction
Hypoxic/ischemic brain injury
Neonatal abstinence syndrome
Intrauterine fetal death
Premature labor and delivery
Preterm, premature rupture of membranes
Source: Reference 6
Opioid agonist therapy
Obstetric complications in women with OUD may be related to rapid, frequent fluctuations of opioid blood levels during intoxication and withdrawal. Therefore, the first goal of pharmacotherapy is to reduce physical stress associated with cycling opioid blood levels. Opioid agonist medications can be extremely effective. Opioid agonist treatment for pregnant patients is similar to that of nonpregnant patients but includes pregnancy-specific objectives ( Table 4 ). 20
Few anti-relapse medications have been studied in pregnant patients. Pharmacotherapies for OUD include methadone and buprenorphine. In our experience, opioid antagonists such as naltrexone typically would not be considered for pregnant patients because:
- their expected efficacy in reducing relapse in pregnant patients is lower than that of other medications
- their expected risk for inducing withdrawal is higher compared with methadone or buprenorphine
- research on the use of naltrexone during pregnancy is lacking.
Methadone has been used to treat OUD during pregnancy since the late 1970s. 5 It requires adherence to strict federal regulations and is FDA pregnancy class C (animal reproduction studies have shown an adverse effect on the fetus and there are no adequate well-controlled studies in humans, but potential benefits may warrant use in pregnant women despite potential risks). Pregnant women have been safely maintained on methadone without adverse long-term maternal or fetal effects, and the National Institutes of Health recommends it as the standard of care for pregnant women with OUD. A woman steadily maintained on methadone is more likely to have a healthy pregnancy and infant than a woman who uses alcohol or other drugs. 21 Further, the structure and services of methadone maintenance treatment can improve compliance with prenatal care and help prepare patients for parental responsibilities.