A Systematic Scoping Review of Peridelivery Pain Management for Pregnant People With Opioid Use Disorder

From the Society for Obstetric Anesthesia and Perinatology and Society for Maternal Fetal Medicine

Grace Lim, MD, MSc; Mieke Soens, MD; Anne Wanaselja, MD; Arthur Chyan, MD; Brendan Carvalho, MBBS, FRCA; Ruth Landau, MD; Ronald B. George, MD; Mary Lou Klem, PhD, MLIS; Sarah S. Osmundson, MD, MS; Elizabeth E. Krans, MD, MS; Mishka Terplan, MD, MPH, FACOG, DFASAM; Brian T. Bateman, MD, MSc

Disclosures

Anesth Analg. 2022;135(5):912-925. 

In This Article

Abstract and Introduction

Abstract

The prevalence of pregnant people with opioid use disorder (OUD), including those receiving medications for opioid use disorder (MOUD), is increasing. Challenges associated with pain management in people with OUD include tolerance, opioid-induced hyperalgesia, and risk for return to use. Yet, there are few evidence-based recommendations for pain management in the setting of pregnancy and the postpartum period, and many peripartum pain management studies exclude people with OUD. This scoping review summarized the available literature on peridelivery pain management in people with OUD, methodologies used, and identified specific areas of knowledge gaps. PubMed and Embase were comprehensively searched for publications in all languages on peripartum pain management among people with OUD, both treated with MOUD and untreated. Potential articles were screened by title, abstract, and full text. Data abstracted were descriptively analyzed to map available evidence and identify areas of limited or no evidence. A total of 994 publications were imported for screening on title, abstracts, and full text, yielding 84 publications identified for full review: 32 (38.1%) review articles, 14 (16.7%) retrospective studies, and 8 (9.5%) case reports. There were 5 randomized controlled trials. Most studies (64%) were published in perinatology (32; 38.1%) journals or anesthesiology (22; 26.2%) journals. Specific areas lacking trial or systematic review evidence include: (1) methods to optimize psychological and psychosocial comorbidities relevant to acute pain management around delivery; (2) alternative nonopioid and nonpharmacologic analgesia methods; (3) whether or not to use opioids for severe breakthrough pain and how best to prescribe and monitor its use after discharge; (4) monitoring for respiratory depression and sedation with coadministration of other analgesics; (5) optimal neuraxial analgesia dosing and adjuncts; and (6) benefits of abdominal wall blocks after cesarean delivery. No publications discussed naloxone coprescribing in the labor and delivery setting. We observed an increasing number of publications on peripartum pain management in pregnant people with OUD. However, existing published works are low on the pyramid of evidence (reviews, opinions, and retrospective studies), with a paucity of original research articles (<6%). Opinions are conflicting on the utility and disutility of various analgesic interventions. Studies generating high-quality evidence on this topic are needed to inform care for pregnant people with OUD. Specific research areas are identified, including utility and disutility of short-term opioid use for postpartum pain management, role of continuous wound infiltration and truncal nerve blocks, nonpharmacologic analgesia options, and the best methods to support psychosocial aspects of pain management.

Introduction

During the past decade, opioid use disorder (OUD) has increased 4-fold among pregnant people.[1] OUD increases risk for death from overdose, which is a rising leading cause of maternal deaths in the United States (Centers for Disease Control and Prevention [CDC]: https://www.cdc.gov/reproductivehealth/opioid-use-disorder-pregnancy/index.html). Peridelivery pain management for pregnant patients with OUD is suboptimal because of lack of evidence-based recommendations. Research suggests that suboptimal relief of acute postoperative pain has long-term sequelae, including chronic pain and depression.[2,3] This problem of pain management is further complicated in patients with OUD because of concerns about return to use, triggered by pain itself or triggered by exposure to opioids if opioids must be used for pain control.

Medications for opioid use disorder (MOUD) is the mainstay for effective treatment of OUD in pregnancy because MOUD is associated with better prenatal care adherence and birth outcomes.[4] MOUD in pregnancy typically includes opioid agonist or mixed agonist-antagonist medications (eg, methadone and buprenorphine). Chronic use of these medications can have implications on pain management during and after labor and delivery. These medications have a strong affinity for μ-opioid receptors, which, in theory, may increase the likelihood of higher doses of opioids needed or consumed to control pain during labor and after delivery. However, in contrast, both opioid exposure and untreated or poorly controlled pain can lead to return to use or OUD recurrence.[5] How clinicians should optimally manage both acute pain and coexisting OUD is a source of frequent debate.

It is unclear what type of information is available in literature about pain management in patients with coexisting OUD. Systematically mapping the current research done and knowledge gaps, as well as existing limitations in study methodologies, will assist with planning specific directions for future research. The purpose of this scoping review is to identify and summarize the available literature on peripartum pain management in pregnant people with OUD, both treated with MOUD and untreated. The focus of this review is on 3 primary peripartum periods: predelivery pain management optimization; pain management in labor and delivery; and postcesarean delivery pain management. The scoping review aimed to characterize available evidence on how OUD affects pain management during the 3 peripartum periods mentioned above and to identify knowledge gaps to make recommendations for future research.

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