Opioid Detoxification During Pregnancy

Abstract

OBJECTIVE To systematically review maternal and neonatal outcomes associated with opioid detoxification during pregnancy. DATA SOURCES PubMed, PsycINFO, EMBASE, Cochrane, and ClinicalTrials.gov databases were searched from January 1, 1966, to September 1, 2016. METHODS OF STUDY SELECTION English-language studies that reported outcomes associated with opioid detoxification among pregnant women with opioid use disorder were included. Nonoriginal research articles (case reports, editorials, reviews) and studies that failed to report outcomes for detoxification participants were excluded. Bias was assessed using the Cochrane Collaboration’s tool for assessing risk of bias and quality was assessed using the U.S. Preventive Service Task Force Quality of Evidence scale. TABULATION, INTEGRATION, AND RESULTS Of 1,315 unique abstracts identified, 15 met criteria for inclusion and included 1,997 participants, of whom 1,126 underwent detoxification. Study quality ranged from fair to poor as a result of the lack of a randomized control or comparison arm and high risk of bias across all studies. Only nine studies had a comparison arm. Detoxification completion (9–100%) and illicit drug relapse (0–100%) rates varied widely across studies depending on whether data from participants who did not complete detoxification or who were lost to follow-up were included in analyses. The reported rate of fetal loss was similar among women who did (14 [1.2%]) and did not undergo detoxification (17 [2.0%]). CONCLUSIONS Evidence does not support detoxification as a recommended treatment intervention as a result of low detoxification completion rates, high rates of relapse, and limited data regarding the effect of detoxification on maternal and neonatal outcomes beyond delivery.

Fetal Outcomes with Detoxification from Opioid Drugs during Pregnancy: A Systematic Review

“…As this study was in preparation, Terplan et al published a systematic review evaluating both maternal and neonatal outcomes with opioid drug detoxification in pregnancy. 56 Their review included two studies that ours did not. One was a 1975 publication that included patients who were managed prior to 1980.…”

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

“…In the largest systematic review to date that included 1126 pregnant women with OUD who underwent opioid detoxification, rates of successful detoxification (9e100%) and illicit drug use (0e100%) were widely variable. 101 The high rates of successful detoxification (as high as 100% in some studies) as judged by no evidence of opioid use recurrence on urine drug screen at the time of delivery occurred in studies in which women were in inpatient residential treatment programs, including involuntary institutionalization. The rates of relapse were dependent on the inclusion or exclusion of women who were lost to follow-up.…”

“…Similarly, given the significant bias and poor-to-fair quality of previous studies, at present any risks for pregnancy, fetal, and newborn complications that are associated with opioid withdrawal during pregnancy remain both unidentified and unquantified. 101 The elements of optimal care for pregnant women who choose medication-assisted withdrawal have not been well described, and future research in this area is needed before it can be recommended as a standard option.…”

Maternity Care for Pregnant Women with Opioid Use Disorder: A Review

“…Current recommendations for treating women with OUD during pregnancy emphasize behavioral therapy and access to pharmacotherapy, including methadone, buprenorphine (Subutex), or buprenorphine‐naloxone (Suboxone) . Two recent systematic reviews have found that detoxification, defined as assisted or unassisted withdrawal from opioids without initiation of pharmacotherapy, increases the risk of relapse . However, despite current recommendations, the majority of pregnant women with OUD do not receive pharmacotherapy during pregnancy .…”