Pregnant Patients on Chronic Opioids

Overview: 

Background: Pregnant individuals on chronic opioids fall into 3 distinct groups. 

  1. Those with chronic pain syndromes on opioids. 
  2. Those with opioid use disorder on medications (MOUD). 
  3. Those with an untreated opioid use disorder.

All 3 groups have unique pain control needs and often suffer from undertreated pain.

Clinical Challenges

  • Treating pain adequately during labor and delivery given higher baseline opioid tolerance. 
  • Providing adequate post-operative pain control without oversedation in the postpartum period. 
  • Supporting recovery goals for those in recovery by encouraging the continuation of medications for opioid use disorder. 
  • Supporting the treatment of the parent-infant dyad to minimize the occurrence of neonatal opioid withdrawal.
  • Encouraging breast feeding.

Special Considerations

  • Continued use of medications to treat opioid use disorders (MOUD) should be encouraged throughout pregnancy, labor and delivery, and the postpartum period to prevent return to use which can be fatal. Opioid overdose is a leading cause of maternal mortality in the postpartum period.
  • Partial agonist/antagonists such as nalbuphine and butorphanol should be avoided in pregnant individuals who are dependent on opioids as they can precipitate withdrawal with resulting fetal intolerance of labor.
  • Nicotine withdrawal worsens pain control. Tobacco cessation should be encouraged, however, and nicotine replacement therapy routinely ordered.

Clinical Recommendations

Suggestions for best practices
Antepartum and Labor
  • Consultation with anesthesia can be very helpful during antepartum care to address concerns over pain control during L&D and the postpartum period.
  • Continued provision of buprenorphine or methadone (at pre-labor doses) should be continued throughout labor and delivery.
  • Neuraxial analgesia should be administered as soon as desired.
    • For patients with contraindications to neuraxial analgesia or for those who refuse it, opioid-based patient-controlled analgesia (PCA) may be offered
    • Avoid using opioid agonist/antagonist drugs for labor analgesia
    • Nitrous oxide should be used with caution in patients who take opioids because of added risk of respiratory depression
    • Initiate labor analgesia for patients with chronic opioid use or OUD according to standard institutional protocol.
    • Frequent assessments will help guide any necessary modifications such considering a higher concentration local anesthetic and/or opioid, higher rates of infusions or the addition of neuraxial adjuncts such as clonidine or epinephrine.
Post-partum (vaginal delivery)
  • Non-opioid pharmacotherapy
    • Acetaminophen 1 g IV (if not able to take po) or 975 mg po q 6 hours scheduled. Can start this during labor and delivery
    • NSAIDS ketorolac 30 mg IV q 6 hours scheduled until taking po, then ibuprofen 600 mg po q 6 or naproxen 500 mg po q 8 starting postpartum or post operatively
  • Other medications and support
    • Lidocaine patch/spray
    • Ice/heat packs
    • Scheduled stool softeners (especially if complicated repair)
    • Emphasized benefits of good nutrition
    • Hydration
    • Ambulation
    • "Parental love and baby bonding" is the best pain medication
  • Opioids reserved for severe pain unresponsive to above measures. Usually only needed for a day or two.
Post-partum (C-section)
  • Non-opioid pharmacotherapy
    • Acetaminophen 1 g IV (if not able to take po) or 975 mg po q 6 hours scheduled. Can start this during labor and delivery
    • NSAIDS ketorolac 30 mg IV q 6 hours scheduled until taking po, then ibuprofen 600 mg po q 6 or naproxen 500 mg po q 8 starting postpartum or post operatively
  • Less commonly used options that can be used as adjuncts.
    • Gabapentin 300 mg po (or pregabalin 150 mg) one hour prior to c/s and then 200 mg q 8 hours post-op
    • Low-dose ketamine (10 mg prior to c/s has been shown to improve pain control at 2 weeks)
    • Clonidine 0.1 mg po q 8 hours prn anxiety/withdrawal symptoms (if blood pressure can tolerate)
    • Hydroxyzine 25-50 mg po q 6 hours prn
      nausea/vomiting/dysphoria/anxiety.
  • Neuraxial morphine should be standard. There is limited evidence on dosing in this context. To limit side effects the lowest effective dose should be considered (100 mcg [spinal], 1.5 mg [epidural]). Neuraxial opioid pruritus can be managed with ondansetron to avoid opioid antagonist.
    • Some centers use PCEA for 24 hours post-operatively, though this will limit mobilization and the potential risks should be considered.
  • Transverse Abdominus Plane (TAP) block can be helpful in case of general anesthesia
  • Opioid Pain Management: Severe, intractable pain:
    • Hydromorphone PCA x 6-12 hours: dose range 0.2-1 mg (0.6-2mg) if unable to tolerate oral medications
    • Transition to PO hydromorphone 2-6mg Q3H prn- 3-5 times normal dosing
  • Other medications and Important Support
    • Lidocaine patch
    • Abdominal binder
    • Scheduled stool softeners
    • Emphasized benefits of good nutrition
    • Hydration
    • Ambulation
    • "Parental love and baby bonding" is the best pain medication
    • Encourage breast or chest feeding and parental non-separation to help prevent neonatal withdrawal.
References: 

Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med 2006 Jan 17;144(2):127-34. 

Hoflich A. S. LM, Jagsch R., et al. Peripartum pain management in opioid dependent women. European Journal of Pain 2012;16:574–84.

Meyer M Wright T. Labor and Delivery Management in Women with Substance Use Disorders. In: Wright TE, editor. Opioid Use Disorders in Pregnancy, Management Guidelines for Improving Outcomes. Cambridge UK: Cambridge University Press; 2018. p. 93-104. 

Ecker J, Abuhamad A, Hill W, Bailit J, Bateman BT, Berghella V, Blake-Lamb T, Guille C, Landau R, Minkoff H, Prabhu M, Rosenthal E, Terplan M, Wright TE, Yonkers KA. Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine. Am J Obstet Gynecol. 2019 Jul;221(1):B5-B28. doi: 10.1016/j.ajog.2019.03.022. Epub 2019 Mar 27. PMID: 30928567.