Treating Women Who Are Pregnant and Parenting for Opioid Use Disorder and the Concurrent Care of Their Infants and Children: Literature Review to Support National Guidance

Abstract

Objectives:The prevalence of opioid use disorder (OUD) during pregnancy is increasing. Practical recommendations will help providers treat pregnant women with OUD and reduce potentially negative health consequences for mother, fetus, and child. This article summarizes the literature review conducted using the RAND/University of California, Los Angeles Appropriateness Method project completed by the US Department of Health and Human Services Substance Abuse and Mental Health Services Administration to obtain current evidence on treatment approaches for pregnant and parenting women with OUD and their infants and children.Methods:Three separate search methods were employed to identify peer-reviewed journal articles providing evidence on treatment methods for women with OUD who are pregnant or parenting, and for their children. Identified articles were reviewed for inclusion per study guidelines and relevant information was abstracted and summarized.Results:Of the 1697 articles identified, 75 were included in the literature review. The perinatal use of medication for addiction treatment (MAT, also known as medication-assisted treatment), either methadone or buprenorphine, within comprehensive treatment is the most accepted clinical practice, as withdrawal or detoxification risks relapse and treatment dropout. Medication increases may be needed with advancing pregnancy, and are not associated with more severe neonatal abstinence syndrome (NAS). Switching medication prenatally is usually not recommended as it can destabilize opioid abstinence. Postnatally, breastfeeding is seen as beneficial for the infant for women who are maintained on a stable dose of opioid agonist medication. Less is known about ideal pain management and postpartum dosing regimens. NAS appears generally less severe following prenatal exposure to buprenorphine versus methadone. Frontline NAS medication treatments include protocol-driven methadone and morphine dosing in the context of nonpharmacological supports.Conclusions:Women with OUD can be treated with methadone or buprenorphine during pregnancy. NAS is an expected and manageable condition. Although research has substantially advanced, opportunities to guide future research to improve maternal and infant outcomes are provided.

Medication Use and Pain Management in Pregnancy: A Critical Review

“…Use in pregnancy is expected to grow further due to increases in maternal age, prevalence of medical comorbidities, and chronic pain among pregnant women . Opioid dependence is also increasingly common among women of reproductive age and may require management with opioid replacement therapy …”

“…Opioid dependence is increasing among women of reproductive age using both prescribed or illicit opioids . Untreated opioid dependence in pregnancy is associated with numerous adverse maternal and fetal outcomes, including poor antenatal care, blood‐borne viruses, low birth weight, and intrauterine growth restriction . Treatment options include continuation of prescribed opioids, an opioid taper, medication‐assisted withdrawal, or maintenance treatment with a long‐acting opioid agonist such as methadone or BPN.…”

“…This approach allows for maintenance of a steady opioid concentration, thus avoiding repeated episodes of intoxication and withdrawal and associated harmful fetal effects. MAT with methadone or BPN during pregnancy is associated with reduced rates of illicit opioid use, increased prenatal treatment retention, decreased pregnancy complications, and improved fetal outcomes compared with untreated opioid dependence in pregnancy . BPN should be considered for women who are already stabilized on this medication and for women who are naïve to opioid agonist therapy, but studies do not generally support a change to BPN for women who are already stabilized on methadone .…”

Opioid Detoxification During Pregnancy

“…45 Most participants in the included studies voluntarily participated in the detoxification process, which emphasizes the importance of pregnancy as a time of enhanced maternal investment in behavior change. However, taking advantage of the “pregnancy opportunity” to reinforce patient fears related to fetal opioid exposure and withdrawal by ceasing or not initiating pharmacotherapy should not be the primary driving force behind prevention and treatment efforts.…”

Magnetocardiographic identification of prolonged fetal corrected QT interval in women receiving treatment for opioid use disorder

“…The opioid epidemic continues to affect many communities across the United States . The current standard of care is to provide medication‐assisted treatment for opioid use disorder (OUD) during pregnancy . Long‐acting opioids, such as methadone, have been traditionally used.…”