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How does a clinician approach the pharmacological management of opioid use disorders in pregnant women and pregnant people?
The United States remains in the midst of at least its third opioid overdose epidemic. Within this current overdose epidemic are several distinct waves beginning with prescription opioid deaths in the late 1990s followed heroin overdose deaths in 2010 and since 2013 an ever-rising rate in fatal overdoses involving synthetic opioids (e.g. fentanyl). While opioid use disorder rates have been stable over time, dying from opioids greatly increased with a 25.9% increase in opioid-related overdose deaths from April 2020 to April 2021, representing 56,064 and 75,673 deaths, respectively [1]. In 2017, economists estimated the economic burden of opioid use disorder (OUD) and fatal opioid overdose on the USA was $1.02 trillion [2]. Like other substance use patterns, rates of opioid use among pregnant women and pregnant people have paralleled the non-pregnant population. From 2000 to 2017, the national rates of maternal OUD at delivery increased from 1.1 to 8.2 per 1000 delivery hospitalizations [3,4]. Likewise, the diagnoses of opioid withdrawal following prenatal opioid exposure, also known as neonatal abstinence syndrome or neonatal opioid withdrawal syndrome (NAS/NOWS), increased from 1.2 to 7.3 per 1000 birth hospitalizations from 2000 to 2017 [4,5].
The harms of untreated OUD during pregnancy compared with those without OUD included increased odds of maternal cardiac arrest, preterm labor, placental abruption, premature rupture of membranes, cesarean delivery and death during hospitalization. For the neonates born to pregnant women and pregnant people with untreated OUD compared to neonates born to birthing people without OUD, they were at increased odds of intrauterine growth restriction, oligohydramnios, and stillbirth [6]. Risk factors for adverse neonatal outcomes may be related to contextual factors of living in marginalized contexts such as inadequate nutrition, stress, and trauma, rather than to the substance of prenatal exposure [6]. Complications in the prenatally opioid-exposed neonate may be partially due to fetal asphyxia which may occur during overdose or withdrawal [7]. Further, neonates diagnosed with NAS/NOWS may have longer and more complicated hospital stays than non-prenatally opioid exposed neonates [6]. Treatments such as methadone or buprenorphine to treat OUD (known as medication to treat OUD; MOUD) during pregnancy significantly improved birthweight and reduced growth restriction in prenatally exposed neonates compared to neonates born to patients with untreated OUD during pregnancy [8]. Read more here...
Teams and facilities concerned about this issue in maternal health were hard at work developing quality improvement plans on January 12th at the kickoff to PQCNC clOUDi 3.0 - Were you there? Was your facility represented? It's not too late to stand up and be counted - get started here
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