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Pregnancy and the Opioid Epidemic

  • Substance Use Disorders (FG Moeller, Section Editor)
  • Published:
Current Treatment Options in Psychiatry Aims and scope Submit manuscript

Opinion Statement

The USA is currently experiencing related epidemics of opioid misuse, use disorder, (over) prescribing, and overdose. We review the current literature on opioid use disorder (OUD) during pregnancy including intrapartum and postpartum considerations, breastfeeding, neonatal abstinence syndrome, and contraception. Screening for OUD in pregnancy should be universal, and pregnant women with opioid use disorder should have access to opioid pharmacotherapy. Pharmacotherapy with opioid agonists, methadone, or buprenorphine remains the standard of care for treating opioid use disorder in pregnancy. Medically assisted opioid withdrawal is associated with high maternal relapse rates and without demonstrable benefit for mother or newborn. Extended release naltrexone is emerging as treatment option for carefully selected pregnant and postpartum women. Breastfeeding for women stabilized on opioid pharmacotherapy is safe and beneficial for the mother-infant dyad. Enhanced postpartum care for these women should include relapse prevention, recovery support, promotion of breastfeeding to reduce neonatal abstinence syndrome, access to contraception, and synchronized transfer to primary care and addiction medicine specialists.

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Notes

  1. State policy in regard to substance use in pregnancy

    Substance use during pregnancy considered child abuse: Alabama, Arkansas, Colorado, District of Columbia, Florida, Illinois, Indiana, Iowa, Louisiana, Maryland, Minnesota, Missouri, Nevada, North Dakota, Oklahoma, Rhode Island, South Carolina, South Dakota, Texas, Utah, Virginia, Washington, and Wisconsin

    Reporting mandated when drug use during pregnancy suspected: Alaska, Arkansas, California, District of Columbia, Illinois, Iowa, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nevada, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode Island, Utah, Virginia, and Wisconsin

    (https://www.guttmacher.org/state-policy/explore/substance-abuse-during-pregnancy)

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Substance and Shadow — Stephen R. Kandall | Harvard University Press [Internet]. [cited 2016 Dec 19]. Available from: http://www.hup.harvard.edu/catalog.php?isbn=9780674853614

  2. Darnall BD, Stacey BR, Chou R. Medical and psychological risks and consequences of long-term opioid therapy in women. Pain Med Malden Mass. 2012;13(9):1181.

    Article  Google Scholar 

  3. McHugh RK, DeVito EE, Dodd D, Carroll KM, Potter JS, Greenfield SF, et al. Gender differences in a clinical trial for prescription opioid dependence. J Subst Abus Treat. 2013;45(1):38.

    Article  Google Scholar 

  4. Key Substance Use and Mental Health Indicators in the United States: Results from the 2015 National Survey on Drug Use and Health - NSDUH-FFR1–2015.pdf [Internet]. [cited 2016 Dec 21]. Available from: https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/NSDUH-FFR1-2015.pdf

  5. Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry. 2014;71(7):821–6.

    Article  PubMed  Google Scholar 

  6. TEDS 2004–2014 National Admissions to Substance Abuse Treatment Services - 2014_teds_rpt_natl.pdf [Internet]. [cited 2016 Dec 21]. Available from: https://wwwdasis.samhsa.gov/dasis2/teds_pubs/2014_teds_rpt_natl.pdf

  7. • Jones HE, Fielder A. Neonatal abstinence syndrome: historical perspective, current focus, future directions. Prev Med. 2015;80:12–7. Review of the history of neonatal abstinence syndrome, its treatment and focus on future research directions.

    Article  PubMed  Google Scholar 

  8. O’Malley M, Brown AG, Sharfstein JM. Maryland maternal mortality review. [cited 2016 Dec 19]; Available from: http://phpa.dhmh.maryland.gov/mch/documents/2011mmrrpt.pdf

  9. • Wright TE, Terplan M, Ondersma SJ, Boyce C, Yonkers K, Chang G, et al. The role of screening, brief intervention, and referral to treatment in the perinatal period. Am J Obstet Gynecol. 2016;215(5):539–47. Comprehensive review of screening, brief intervention, and referral to treatment during pregnancy. Highlights the importance of universal screening and reviews different instruments.

    Article  PubMed  Google Scholar 

  10. ACOG Statement on Opioid Use During Pregnancy - ACOG [Internet]. [cited 2016 Nov 21]. Available from: http://www.acog.org/About-ACOG/News-Room/Statements/2016/ACOG-Statement-on-Opioid-Use-During-Pregnancy

  11. Kampman K, Jarvis M. American Society of Addiction Medicine (ASAM) National Practice Guideline for the use of medications in the treatment of addiction involving opioid use. J Addict Med. 2015;9(5):358.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. •• WHO. Guidelines for the identification and management of substance use and substance use disorders in pregnancy. 2014. Comprehensive review with the most complete summary of screening instruments for SUD in pregnancy to date.

  13. Albright B, de la Torre L, Skipper B, Price S, Abbott P, Rayburn W. Changes in methadone maintenance therapy during and after pregnancy. J Subst Abus Treat. 2011;41(4):347–53.

    Article  Google Scholar 

  14. Petersen R, Connelly A, Martin SL, Kupper LL. Preventive counseling during prenatal care: pregnancy risk assessment monitoring system (PRAMS). Am J Prev Med. 2001;20(4):245–50.

    Article  CAS  PubMed  Google Scholar 

  15. McCarthy JJ, Leamon MH, Finnegan LP, Fassbender C. Opioid dependence and pregnancy: minimizing stress on the fetal brain. Am J Obstet Gynecol [Internet]. [cited 2016 Nov 14]; Available from: http://www.sciencedirect.com/science/article/pii/S0002937816308663

  16. Committee opinion no. 633: Alcohol abuse and other substance use disorders: ethical issues in obstetric and gynecologic practice. Obstet Gynecol. 2015;125(6):1529–37.

  17. Schempf AH, Strobino DM. Drug use and limited prenatal care: an examination of responsible barriers. Am J Obstet Gynecol. 2009;200(4):412.e1–412.e10.

    Article  Google Scholar 

  18. Substance abuse during pregnancy [Internet]. Guttmacher Institute. 2016. [cited 2017 Feb 17]. Available from: https://www.guttmacher.org/state-policy/explore/substance-abuse-during-pregnancy

  19. Kaltenbach K, Berghella V, Finnegan L. Opioid dependence during pregnancy: effects and management. Obstet Gynecol Clin N Am. 1998;25(1):139–51.

    Article  CAS  Google Scholar 

  20. Finnegan LP. Treatment issues for opioid-dependent women during the perinatal period. J Psychoactive Drugs. 1991;23(2):191–201.

    Article  CAS  PubMed  Google Scholar 

  21. Saia KA, Schiff D, Wachman EM, Mehta P, Vilkins A, Sia M, et al. Caring for pregnant women with opioid use disorder in the USA: expanding and improving treatment. Curr Obstet Gynecol Rep. 2016:1–7.

  22. Buprenorphine/naloxone versus methadone for the treatment of opioid dependence: a review of comparative clinical effectiveness, cost-effectiveness and guidelines [Internet]. Ottawa: Canadian Agency for Drugs and Technologies in Health; 2016. [cited 2016 Nov 13]. (CADTH Rapid Response Reports). Available from: http://www.ncbi.nlm.nih.gov/books/NBK385163/

  23. Minozzi S, Amato L, Bellisario C, Ferri M, Davoli M. Maintenance agonist treatments for opiate-dependent pregnant women. In: Cochrane Database of Systematic Reviews [Internet]. John Wiley & Sons, Ltd; 2013. [cited 2017 Feb 18]. Available from: doi:10.1002/14651858.CD006318.pub3/abstract

  24. Meyer MC, Johnston AM, Crocker AM, Heil SH. Methadone and buprenorphine for opioid dependence during pregnancy: a retrospective cohort study. J Addict Med. 2015;9(2):81–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. •• Zedler BK, Mann AL, Kim MM, Amick HR, Joyce AR, Murrelle EL, et al. Buprenorphine compared with methadone to treat pregnant women with opioid use disorder: a systematic review and meta-analysis of safety in the mother, fetus and child. Addict Abingdon Engl. 2016. Systematic review of methadone versus buprenorphine during pregnancy. Most detailed data regarding medication and outcome to date.

  26. Lund IO, Fischer G, Welle-Strand GK, O’Grady KE, Debelak K, Morrone WR, et al. A comparison of buprenorphine + naloxone to buprenorphine and methadone in the treatment of opioid dependence during pregnancy: maternal and neonatal outcomes. Subst Abuse Res Treat. 2013;7:61–74.

    Article  CAS  Google Scholar 

  27. Jumah NA, Edwards C, Balfour-Boehm J, Loewen K, Dooley J, Gerber Finn L, et al. Observational study of the safety of buprenorphine + naloxone in pregnancy in a rural and remote population. BMJ Open [Internet]. 2016;6(10). [cited 2016 Nov 15]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5093362/

  28. Newman RG, Gevertz SG. Comment on “a comparison of buprenorphine + naloxone to buprenorphine and methadone in the treatment of opioid dependence during pregnancy: maternal and neonatal outcomes.”. Subst Abuse Res Treat. 2013;7:107–8.

    Article  Google Scholar 

  29. Pond SM, Kreek MJ, Tong TG, Raghunath J, Benowitz NL. Altered methadone pharmacokinetics in methadone-maintained pregnant women. J Pharmacol Exp Ther. 1985;233(1):1–6.

    CAS  PubMed  Google Scholar 

  30. Wolff K, Boys A, Rostami-Hodjegan A, Hay A, Raistrick D. Changes to methadone clearance during pregnancy. Eur J Clin Pharmacol. 2005;61(10):763–8.

    Article  CAS  PubMed  Google Scholar 

  31. Swift RM, Dudley M, DePetrillo P, Camara P, Griffiths W. Altered methadone pharmacokinetics in pregnancy: implications for dosing. J Subst Abus. 1989;1(4):453–60.

    CAS  Google Scholar 

  32. Seligman NS, Almario CV, Hayes EJ, Dysart KC, Berghella V, Baxter JK. Relationship between maternal methadone dose at delivery and neonatal abstinence syndrome. J Pediatr. 2010;157(3):428–433, 433.e1.

  33. Farid WO, Lawrence AJ, Krstew EV, Tait RJ, Hulse GK, Dunlop SA. Maternally administered sustained-release naltrexone in rats affects offspring neurochemistry and behaviour in adulthood. PLoS ONE [Internet]. 2012;7(12). [cited 2016 Dec 19]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3530485/

  34. Hulse G, O’Neil G. Using naltrexone implants in the management of the pregnant heroin user. Aust N Z J Obstet Gynaecol. 2002;42(5):569–73.

    Article  CAS  PubMed  Google Scholar 

  35. Hulse GK, Arnold-Reed DE, O’Neil G, Hansson RC. Naltrexone implant and blood naltrexone levels over pregnancy. Aust N Z J Obstet Gynaecol. 2003;43(5):386–8.

    Article  PubMed  Google Scholar 

  36. Hulse G, O’Neill G. A possible role for implantable naltrexone in the management of the high-risk pregnant heroin user. Aust N Z J Obstet Gynaecol. 2002;42(1):104–5.

    Article  Google Scholar 

  37. Jones HE. Acceptance of naltrexone by pregnant women enrolled in comprehensive drug addiction treatment: an initial survey. Am J Addict. 2012;21(3):199–201.

    Article  PubMed  Google Scholar 

  38. Cousins SJ, Radfar SR, Crèvecoeur-MacPhail D, Ang A, Darfler K, Rawson RA. Predictors of continued use of extended-released naltrexone (XR-NTX) for opioid-dependence: an analysis of heroin and non-heroin opioid users in Los Angeles County. J Subst Abus Treat. 2016;63:66–71.

    Article  Google Scholar 

  39. •• Jones HE, Chisolm MS, Jansson LM, Terplan M. Naltrexone in the treatment of opioid-dependent pregnant women: the case for a considered and measured approach to research. Addiction. 2013;108(2):233–47. Encompassing review of the medical literature on naltrexone use in pregnancy highlighting outcomes of experimental animal studies, human observational studies of maternal and neonatal outcomes within harm reduction models, in-depth discussion of ethical and clinical implications of naltrexone use for obstetric practitioners, and the need for future research with a road map for accomplishment.

    Article  PubMed  Google Scholar 

  40. Rementeriá JL, Nunag NN. Narcotic withdrawal in pregnancy: stillbirth incidence with a case report. Am J Obstet Gynecol. 116(8):1152–6.

  41. Zuspan FP, Gumpel JA, Mejia-Zelaya A, Madden J, Davis R. Fetal stress from methadone withdrawal. Am J Obstet Gynecol. 122(1):43–6.

  42. Dashe JS, Jackson GL, Olscher DA, Zane EH, Wendel GD. Opioid detoxification in pregnancy. Obstet Gynecol. 1998;92(5):854–8.

    CAS  PubMed  Google Scholar 

  43. Luty J, Nikolaou V, Bearn J. Is opiate detoxification unsafe in pregnancy? J Subst Abus Treat. 2003;24(4):363–7.

    Article  Google Scholar 

  44. Stewart RD, Nelson DB, Adhikari EH, McIntire DD, Roberts SW, Dashe JS, et al. The obstetrical and neonatal impact of maternal opioid detoxification in pregnancy. Am J Obstet Gynecol. 2013;209(3):267.e1–5.

    Article  Google Scholar 

  45. Bell SG. Drug screening in neonates. Neonatal Netw NN. 2016;35(5):321–6.

    Article  PubMed  Google Scholar 

  46. Gender differences in mortality among treated opioid dependent patients [Internet]. [cited 2016 Dec 7]. Available from: http://www.sciencedirect.com.ezproxy.bu.edu/science/article/pii/S0376871615003816

  47. Jones HE, O’Grady KE, Malfi D, Tuten M. Methadone maintenance vs. methadone taper during pregnancy: maternal and neonatal outcomes. Am J Addict. 2008;17(5):372–86.

    Article  PubMed  Google Scholar 

  48. Committee Opinion No. 524: Opioid Abuse, Dependence, and Addiction in Pregnancy. Obstet Gynecol. 2012;119(5):1070–6.

  49. Wong S, Ordean A, Kahan M. Maternal fetal medicine committee, family physicians advisory committee, medico-legal committee, et al. substance use in pregnancy. J Obstet Gynaecol Can JOGC J Obstet Gynecol Can JOGC. 2011;33(4):367–84.

    Google Scholar 

  50. Terplan M, Minkoff H. Neonatal abstinence syndrome and ethical approaches to the identification of pregnant women who use drugs. Obstet Gynecol. 2016 :1.

  51. Mehta PK, Bachhuber MA, Hoffman R, Srinivas SK. Deaths from unintentional injury, homicide, and suicide during or within 1 year of pregnancy in Philadelphia. Am J Public Health. 2016;106(12):2208–10.

    Article  PubMed  Google Scholar 

  52. • CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep [Internet]. 2016;65. [cited 2016 Dec 7]. Available from: http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm. Recent CDC guidelines for opioid prescribing. Emphasis on both initiation and continuation therapy.

  53. Shaffer EE, Pham A, Woldman RL, Spiegelman A, Strassels SA, Wan GJ, et al. Estimating the effect of intravenous acetaminophen for postoperative pain management on length of stay and inpatient hospital costs. Adv Ther. 2016.

  54. • Kocherlakota P. Neonatal abstinence syndrome. Pediatrics. 2014;134(2):e547–61. Review of the chronological history of opioid addiction in the US, identification of NAS, initially termed congenital morphinism, and the first successfully newborn treatment in 1903. A thorough discussion of the neurobiology of NAS, diagnosis and onset of symptoms, meconium toxicology, development and implementation of treatment options; including an algorithm for newborn pharmacotherapy, the role for breastfeeding, importance of discharge planning and out-patient pediatric follow-up.

    Article  PubMed  Google Scholar 

  55. Jones HE, Heil SH, Tuten M, Chisolm MS, Foster JM, Grady KEO, et al. Cigarette smoking in opioid-dependent pregnant women: neonatal and maternal outcomes. Drug Alcohol Depend. 2013;131(3):271.

    Article  PubMed  Google Scholar 

  56. Patrick SW, Schumacher RE, Benneyworth BD, Krans EE, McAllister JM, Davis MM. Neonatal abstinence syndrome and associated health care expenditures: United States, 2000–2009. JAMA J Am Med Assoc. 2012;307(18):1934–40.

    Article  CAS  Google Scholar 

  57. •• DEM W, DMJ H, DMS B, Paul DJ, Harvey-Wilkes DK, Terrin DN, et al. Association of OPRM1 and COMT single-nucleotide polymorphisms with hospital length of stay and treatment of neonatal abstinence syndrome. JAMA. 2013;309(17):1821. Prospective multicenter cohort study of 86 mother-infant pairs genotyped for known μ-opioid receptor (OPRM1) and catechol-o-methyltransferase (COMT) genes associated with opioid addiction in adults to determine if the presence of such SNPs in a newborn’s genotype can predict length of hospital stay for NAS. Infants who expressed these adult –associated addiction potential SNPs, the OPM1 and COMT genes, were more likely to have shorter hospital stays.

    Article  Google Scholar 

  58. Standardizing care improves outcomes for infants born with neonatal abstinence syndrome [Internet]. [cited 2016 Dec 19]. Available from: https://public.vtoxford.org/pediatrics-article-on-improving-care-for-nas/

  59. Patrick SW, Schumacher RE, Horbar JD, Buus-Frank ME, Edwards EM, Morrow KA, et al. Improving care for neonatal abstinence syndrome. Pediatrics. 2016;e20153835.

  60. Newman A, Davies GA, Dow K, Holmes B, Macdonald J, McKnight S, et al. Rooming-in care for infants of opioid-dependent mothers. Can Fam Physician. 2015;61(12):e555–61.

    PubMed  PubMed Central  Google Scholar 

  61. Breastfeeding SO. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827–41.

    Article  Google Scholar 

  62. Reece-Stremtan S, Marinelli KA. The academy of breastfeeding medicine. ABM clinical protocol #21: guidelines for breastfeeding and substance use or substance use disorder, revised 2015. Breastfeed Med. 2015;10(3):135–41.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Bagley SM, Wachman EM, Holland E, Brogly SB. Review of the assessment and management of neonatal abstinence syndrome. Addict Sci Clin Pract. 2014;9(1):19.

    Article  PubMed  PubMed Central  Google Scholar 

  64. Tsai LC, Doan TJ. Breastfeeding among mothers on opioid maintenance treatment: a literature review. J Hum Lact Off J Int Lact Consult Assoc. 2016;32(3):521–9.

    Google Scholar 

  65. Cirillo C, Francis K. Does breast milk affect neonatal abstinence syndrome severity, the need for pharmacologic therapy, and length of stay for infants of mothers on opioid maintenance therapy during pregnancy? Adv Neonatal Care Off J Natl Assoc Neonatal Nurses. 2016;16(5):369–78.

    Article  Google Scholar 

  66. Edwards L, Brown LF. Nonpharmacologic management of neonatal abstinence syndrome: an integrative review. Neonatal Netw NN. 2016;35(5):305–13.

    Article  PubMed  Google Scholar 

  67. Tops M, Koole SL, IJzerman H, Buisman-Pijlman FTA. Why social attachment and oxytocin protect against addiction and stress: insights from the dynamics between ventral and dorsal corticostriatal systems. Pharmacol Biochem Behav. 2014;119:39–48.

    Article  CAS  PubMed  Google Scholar 

  68. Heil SH, Jones HE, Arria A, Kaltenbach K, Coyle M, Fischer G, et al. Unintended pregnancy in opioid-abusing women. J Subst Abus Treat. 2011;40(2):199–202.

    Article  Google Scholar 

  69. Baskerville TA, Douglas AJ. Dopamine and oxytocin interactions underlying behaviors: potential contributions to behavioral disorders. CNS Neurosci Ther. 2010;16(3):e92–123.

    Article  CAS  PubMed  Google Scholar 

  70. Terplan M, Hand DJ, Hutchinson M, Salisbury-Afshar E, Heil SH. Contraceptive use and method choice among women with opioid and other substance use disorders: a systematic review. Prev Med. 2015;80:23–31.

    Article  PubMed  PubMed Central  Google Scholar 

  71. Sherman BR, Sanders LM, Yearde J. Role-modeling healthy behavior: peer counseling for pregnant and postpartum women in recovery. Womens Health Issues. 1998;8(4):230–8.

    Article  CAS  PubMed  Google Scholar 

  72. Chinman M, George P, Dougherty RH, Daniels AS, Ghose SS, Swift A, et al. Peer support services for individuals with serious mental illnesses: assessing the evidence. Psychiatr Serv [Internet]. 2014. [cited 2016 Dec 7] Available from: http://ps.psychiatryonline.org/doi/abs/10.1176/appi.ps.201300244?trendmd-shared=0&

  73. Ruiz-Mirazo E, Lopez-Yarto M, McDonald SD. Group prenatal care versus individual prenatal care: a systematic review and meta-analyses. J Obstet Gynaecol Can JOGC J Obstet Gynecol Can JOGC. 2012;34(3):223–9.

    Google Scholar 

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Authors and Affiliations

  1. Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, MA, 02118, USA

    Kelley Saia MD

  2. UNC Horizons and Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Carrboro, NC, 27510, USA

    Hendree Jones PhD

  3. Departments of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology, School of Medicine, Johns Hopkins University, Baltimore, MD, 21224, USA

    Hendree Jones PhD

  4. Departments of Obstetrics and Gynecology and Psychiatry, Virginia Commonwealth University, Box 980034, Richmond, VA, 23298-0034, USA

    Mishka Terplan MD, MPH, FACOG, FASAM

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  1. Kelley Saia MD
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  2. Hendree Jones PhD
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  3. Mishka Terplan MD, MPH, FACOG, FASAM
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Correspondence to Mishka Terplan MD, MPH, FACOG, FASAM.

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Kelley Saia declares that he has no conflict of interest.

Hendree Jones declares that he has no conflict of interest.

Mishka Terplan declares that he has no conflict of interest.

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Saia, K., Jones, H. & Terplan, M. Pregnancy and the Opioid Epidemic. Curr Treat Options Psych 4, 184–195 (2017). https://doi.org/10.1007/s40501-017-0116-y

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