Guidelines on Opioid Use in Pregnancy Released by ACOG

Veronica Hackethal, MD

July 25, 2017

Revised guidelines on treatment of opioid use during pregnancy have been released by the American College of Obstetricians and Gynecologists (ACOG). Medication-assisted treatment remains the recommended treatment, but medically supervised withdrawal can be considered in certain clinical situations, according to the guidelines.

The guidelines provide an updated review of pharmacologic treatment options, including methadone, buprenorphine, naltrexone, and naloxone.

"Concern about medication-assisted treatment must be weighed against the negative effects of ongoing misuse of opioids, which can be much more detrimental to mom and baby. Medication-assisted treatment improves adherence to prenatal care and addiction treatment programs and has been shown to reduce the risk of pregnancy complications," lead author, Maria Mascola, MD, from the Marshfield Clinic in Wisconsin, said in a news release.

Dr Mascola and colleagues published the guidelines online July 25 in Obstetrics & Gynecology.

Opioid use during pregnancy has escalated, in parallel with the opioid epidemic in the general population. Pregnant women who use opioids are at increased risk for pregnancy-associated complications and death. Untreated addiction has also been linked to high-risk behaviors, such as prostitution and crime, which can expose pregnant women to sexually transmitted infections, violence, legal problems, and incarceration. 

Medication-assisted treatment remains the preferred treatment because withdrawal is associated with high relapse rates and poorer outcomes. Relapse is associated with serious risks, such as transmission of infectious agents, accidental overdose as a result of decreased tolerance, lack of prenatal care, and obstetric complications. Medically supervised withdrawal may be considered in women who do not accept treatment with an opioid agonist or when treatment is unavailable.  In that case, a physician experienced in treating perinatal addiction should supervise care, with informed consent of the woman. 

The guidelines also emphasize multidisciplinary long-term follow-up, which should include medical, developmental, and social support.

ACOG also recommends universal screening starting at the first prenatal visit and using a validated verbal screening tool, which is preferable to urine testing. If a woman screens positive, the guidelines recommend a brief intervention (such as a conversation, feedback, and advice) and referral to treatment.

The guidelines also provide detailed information about antepartum, intrapartum, and postpartum care in women who use opioids during pregnancy.

The increasing use of opioids in pregnancy has been accompanied by a sharp increase in neonatal abstinence syndrome — a drug withdrawal syndrome experienced soon after birth in children born to women who take opioids during pregnancy. Consequently, the guidelines emphasize monitoring for this syndrome by a pediatric healthcare provider

"[W]hile neonatal abstinence syndrome is often seen in infants who have been exposed prenatally to opioids, it is important to remember that it is an expected and treatable condition that has not been found to have any significant effect on cognitive development," Dr Mascola added.

Women who are stable, are not using illicit drugs, and have no contraindications (such as HIV infection) should be encouraged to breastfeed, according to the guidelines.  However, providers should counsel women not to breastfeed should they relapse.

Finally, the guidelines emphasize appropriate postpartum psychosocial support, such as substance use disorder treatment and relapse prevention programs. Women should also have routine access to contraceptive services and contraceptive counseling as part of substance use disorder treatment, as the risk for unplanned pregnancy is high among women with substance use disorders and can run as high as 80%.

"The postpartum period is already a vulnerable time for new moms, in general, as they face the stresses of sleep deprivation, caring for a newborn, and possibly symptoms of postpartum depression," Dr Mascola said in the news release. "Women with opioid use disorder are dealing with all those things in addition to the challenges of their addiction, which — without treatment and support — can often lead to relapse. These guidelines are meant to help [obstetrician-gynecologists] ob-gyns assert themselves in the care of their patients, so that they can make a lasting difference in their lives."

The guidelines were supported by the American College of Obstetricians and Gynecologists. The authors have disclosed no relevant financial relationships.

Obstet Gynecol. Published online July 25, 2017. Abstract

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