Opioid use disorder during pregnancy

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.

Table 1

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

Office management

OUD-specific treatment decreases opioid use and improves birth outcomes¹⁴ ; 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 pregnancy¹⁵ 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