The rate of infants being born with opioid addiction has been increasing over the past decade, with most sources linking this with the rising abuse of prescription opioids such as hydrocodone. As clinicians are more likely to encounter women with an opioid abuse disorder who are or may become pregnant, it is vital that they have a clear understanding of the role of opioid-maintenance therapy as well as the effects of opioids on the fetus and the mother. The treatment plan should continue after the birth to ensure the child is cared for adequately and the mother receives the best care possible.
This course is designed for substance abuse counselors, social workers, psychologists, and any professional that assists women who are pregnant and addicted to opioids. The material will also be useful for pediatric nurses working in the neonatal intensive care unit (NICU) and primary care providers in women's health care.
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The purpose of this course is to provide healthcare professionals with the information necessary to appropriately care for pregnant women with opioid dependence who are or are planning to become pregnant in order to minimize the adverse effects on the mother and fetus.
Upon completion of this course, you should be able to:
- Identify the biological effects of opioid use and abuse on women.
- Describe the impact of opioid use on pregnancy and the importance of early recognition and prenatal care.
- Outline the medications used for opioid-maintenance therapy (OMT) in patients who are pregnant.
- Discuss the impact of opioid exposure in utero on fetal development and neonatal health.
- Evaluate the important aspect of discharge planning for infants treated for neonatal abstinence syndrome.
Davina Moss-King, PhD, CRC, CASAC, NCC, is a New York State credentialed alcohol and substance abuse counselor, certified rehabilitation counselor, and a nationally certified counselor with 22 years’ experience counseling women addicted to opioids. The majority of her experience working with women and addiction comes from working at an inpatient facility for detoxification and rehabilitation for substance abuse and assisting women that were pregnant in the facility. As part of her job responsibilities, she assisted women with proper nutrition and aftercare referral plans.
Along with this wealth of experience, Dr. Moss-King is an adjunct professor at Canisius College, Buffalo, New York, in the Counseling and Human Service Department (Counselor Education Division). Here, she is responsible for training graduate students in the area of substance abuse and has expanded to research in the area of women who use opioids before and during pregnancy. She was responsible for creating training sessions for students regarding the consequences of addiction to women and fetuses. Along with creating appropriate treatment recommendations, she is also responsible for researching various programs to be used in the continuation of care after childbirth.
She has completed extensive research in the area of opioid addiction and the recovery process, as evidenced by her dissertations (published in 2005 and 2009). She has also been a contributing author in the area of individual treatment.
Contributing faculty, Davina Moss-King, PhD, CRC, CASAC, NCC, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
Jane C. Norman, RN, MSN, CNE, PhD
Alice Yick Flanagan, PhD, MSW
The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.
Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.
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#93090: Management of Opioid Dependency During Pregnancy
At the juncture of the 21st century, opioid dependence has become a national and international public health problem and dependence involving women has become an epidemic [1,2]. Women are prescribed opioid medications for pain and for various medical ailments more often than men, causing complications such as insomnia, gastrointestinal side effects, tolerance, and dependence. The most common indication for opioid prescriptions for women is chronic pain management, but opioids may also be prescribed following surgery (e.g., cesarean section, hysterectomy) . Codeine, hydrocodone, and oxycodone are the most commonly prescribed opioids, and each of these agents carries a risk for misuse.
An extension of the epidemic of opioid misuse is the public health problem of infants who are exposed to opioids in utero and who exhibit withdrawal symptoms at birth. Local, national, and international reports from neonatal intensive care units (NICUs) have brought awareness to the issue of opioid use and abuse in women. In 2012, U.S. Senator Charles Schumer recommended that the U.S. Food and Drug Administration (FDA) provide clear labels on all opioid medications highlighting the physiological effects for women . The epidemic has affected cities and small towns alike and involves people of all races and ethnicities. As a result, more research has been conducted and programs have been established to heighten awareness of the relationship between opioid use, abuse, and dependence and maternal/fetal health.
This course will highlight the biological effects of opioid use and misuse in women and fetuses. There will be an in-depth examination of the available pharmacologic treatments for the treatment of opioid dependence during pregnancy, also known as opioid-maintenance therapy (OMT), and the effects of OMT on the fetus. Lastly, there will be information regarding the long-term effects of in-utero exposure to opioids for the child.
According to the Centers for Disease Control and Prevention (CDC), women are prescribed opioids at higher doses and for longer periods of time than men . While men continue to be more likely to die of prescription pain medication overdose, this gap is closing. In fact, since 1999, the percentage increase in deaths was more than 400% among women, compared with 265% in men .
Women between 25 and 54 years of age are most likely to be prescribed opioid pain medications, and women between 45 and 54 years of age are most likely to die from an overdose . This may be due in part to the greater incidence of chronic pain syndromes in this patient population . Women who present with chronic pain are more likely than men to be diagnosed with two or more pain conditions and to be diagnosed with migraine headache, irritable bowel syndrome, fibromyalgia, arthritis, and low back, joint, or neck pain . It has also been hypothesized that women may feel more pressure than men to maintain their familial roles as caretaker, spouse, mother, and/or provider despite pain, making their main objective when seeking medical intervention to cease pain and continue activities without interruption rather than seeking a curative, though more disruptive, option . As a result, women may be prescribed opioid medications for a longer duration compared to men, and the duration and amount can lead to dependence. Female opioid abusers are also more likely to abuse other prescription medications, making drug-drug interactions a concern .
Changes in mood and reward behavior
Disruption of neuroendocrine function
Alteration of respiration
Changes in cardiovascular and gastrointestinal function
Potential side effects of opioid use include nausea, vomiting, constipation, dilation of the pupils, impaired ability to swallow, and an itchy feeling on the skin . Women may suffer from secondary amenorrhea as a result of opioid use, defined as absence of menstruation for three or more months . Because amenorrhea is relatively common, women may be unaware of their pregnancy and continue to use or abuse opioids, which can be harmful to the mother as well as the fetus. Other possible adverse effects of opioid use include sedation, cough suppression, dry mouth, and miosis.
Because many oral prescription opioids have half-lives of 24 to 36 hours, users often use at least daily to avoid withdrawal symptoms. Symptoms and signs experienced during withdrawal are:
Ureteric or biliary spasm
The most common symptoms are vomiting, diarrhea, profuse sweating, and tremor/shakiness [13,14]. Withdrawal from opioids requires monitoring and medical management at a facility qualified to provide sensitive and intense care . The facility may be a hospital or an agency structured to specifically care for patients undergoing opioid detoxification. Medical management of detoxification and withdrawal in a specialty facility decreases the risk of injury or death from the withdrawal syndrome . With this approach, methadone or buprenorphine is given for approximately five days at slowly decreasing doses while the vital signs are monitored very closely. Although this method of detoxification is highly recommended for many patients, it is not recommended for pregnant women because of the harmful effects detoxification can have on the fetus [15,17]. During pregnancy, dependent patients are often maintained on specific opioids and dosages in order to avoid withdrawal.
There are several possible reasons a woman who is using opioids may not have obtained appropriate prenatal care:
A history of amenorrhea may result in a delayed realization of pregnancy.
The patient may lack access to health services and/or self-care practices.
The patient may be in active addiction and be regularly participating in high-risk behaviors.
The patient may not realize the importance of obtaining prenatal care.
All female patients taking opioids should be advised of the warning signs of a possible pregnancy, including nausea while not in active withdrawal, tender breasts, sensitivity to unusual smells, and extreme fatigue, and should be instructed to seek immediate medical attention if any of these symptoms are observed . For pregnant women, actively using opioids is associated with an increased risk for obstetric and gynecological complications such as toxemia, communicable infections (e.g., hepatitis C, human immunodeficiency virus [HIV]), low-birth-weight infants, still births, pre-eclampsia, excessive bleeding, miscarriages, small head circumference in offspring, preterm deliveries, and even death [19; 20].
If pregnancy is suspected, a test should be administered, and the immediate focus of care is on the health and safety of the mother and the fetus. The healthcare team may include community workers, a harm-reduction counselor, a chemical dependency counselor, and medical personnel (e.g., obstetrician/gynecologist, primary care physician, nurse practitioner). If a woman is under a physician's care for chronic pain and there is suspicion of pregnancy, the physician should assess the patient's medical condition prior to giving a new or refill prescription. The potential risks of withdrawal and the short- and long-term effects on the fetus (e.g., developmental and congenital disabilities) should be included in patient education.
Methadone, buprenorphine, and buprenorphine/naloxone are used to avoid withdrawal symptoms in non-pregnant opioid-dependent patients. All three options are rated pregnancy category C, meaning animal studies have shown an adverse effect on the fetus in the absence of human studies, but the potential benefits may warrant use in pregnant women despite the risks . Studies conducted through the Substance Abuse and Mental Health Services Administration (SAMHSA) have shown that naloxone can interfere with skeletal development and increase fetal mortality . Therefore, it is recommended that women taking buprenorphine/naloxone prior to becoming pregnant should be transferred to buprenorphine alone for the duration of the pregnancy . Overall, methadone and buprenorphine are the preferred medications used to stabilize the mother and fetus during pregnancy.
Methadone has been the gold standard for opioid maintenance and avoidance of withdrawal during medically managed detoxification since the 1960s, and it remains the preferred option for the management of pregnant women dependent on opioids . As noted, methadone has been classified as pregnancy category C by the FDA because there is a lack of human studies. Although the FDA has concerns, mothers who have been administered methadone properly, under medical supervision, have been found less likely to use other illicit drugs that could harm the fetus .
Methadone maintenance therapy consists of an induction phase and a stabilization phase. The induction phase continues the current methadone dose, if the patient was already on methadone maintenance at the time of pregnancy, or starts an initial dose (based on weight, height, gestational age, and presence of withdrawal symptoms) if the patient has never taken methadone. If treatment is being initiated for the first time, the patient should be admitted to the hospital for approximately 72 hours of observation . During the hospital stay, the opioid levels and the physical status of the mother and the pregnancy are assessed [17,23].
The average dose of methadone for pregnant women is 20–40 mg in the first trimester . As the fetus and placenta increase in size, a medical review is necessary to determine whether an increase of the dose of methadone is needed to avoid potentially harmful withdrawal symptoms. The dose is increased by 10 mg at each stage of significant growth; at the end of the 36 weeks, the average dose is 70 mg. Immediately prior to delivery (38 to 40 weeks), the usual dose is 80 mg . After the birth, additional titration will be necessary, but the medication should be continued. The mother should be closely monitored during the postpartum period to avoid oversedation . An aftercare plan should also be in place for the safety of the mother and the child .
There are medical risks associated with methadone maintenance during pregnancy. One main concern is exposure of infants to the opioid in utero, resulting in acute withdrawal for 3 hours to 12 days after birth. This acute withdrawal is referred to as neonatal abstinence syndrome (NAS), and it is an expected and treatable outcome in infants born following methadone maintenance . Despite the risks, the benefits of methadone generally outweigh the negatives. Infants born to mothers on methadone maintenance are more likely to be born within the 36- to 38-week period and tend to be of average weight than children born to mothers with uncontrolled opioid use.
Methadone can be administered once per day in early pregnancy; however, as the pregnancy progresses, split dosing is recommended . As the dose increases, adverse effects are also more common, including sleep disturbances, excess weight gain, fluid retention, and intolerance to pain during delivery . Any medications typically used for pain management during childbirth should be used with caution.
Another pharmacologic option for opioid maintenance during pregnancy is buprenorphine. This medication is prescribed for women who are unable to take methadone, who were previously taking buprenorphine/naloxone, or who need an immediate change from another opioid .
Buprenorphine is usually administered by an addiction-certified physician . Various studies have found that administration of buprenorphine lowers the use of other drugs, increases the rate of treatment completion, and improves the likelihood of giving birth at term (between 38 and 40 weeks) . Unlike methadone doses, which can increase up to 80 mg, the dosage for buprenorphine is one 4–16 mg tablet per day in the induction period, with a maximum of 24–32 mg per day by the end of the pregnancy. The lower dosage results from the longer half-life (24 to 60 hours, compared to 24 to 36 hours for methadone) .
The birth outcomes with buprenorphine are the same as those outlined for methadone maintenance. However, compared with methadone exposure, infants exposed to buprenorphine in utero have less opioid in their system at birth as measured by urine, umbilical cord, and meconium drug testing and they display less severe NAS symptoms [29,30].
Patients on buprenorphine maintenance will take one tablet per day for the duration of the pregnancy, making compliance easier than with the split doses of methadone. Additional clinical trials are needed to determine if the efficacy of buprenorphine is comparable to methadone.
Even in a supervised environment, opioid use during pregnancy can have negative effects on the fetus, and there is a significant risk of congenital birth defects. Infants born to mothers who used opioids during pregnancy may develop [31,48]:
Congenital heart defects (e.g., conoventricular septal defect, hypoplastic left heart syndrome, atrial septal defect, tetralogy of Fallot, pulmonary valve stenosis)
The heart and eyes appear to be most severely affected, particularly in the first three weeks of pregnancy . Long-term effects to offspring include language and cognitive deficits as well as behavior problems and issues with social acceptance by school-age peers .
All healthcare professionals caring for a woman during labor and delivery should be aware that she is undergoing OMT [23,32]. As discussed, additional medications for pain relief may be necessary, as the maintenance dose of methadone or buprenorphine will not offer analgesia. The American College of Obstetricians and Gynecologists (ACOG) recommends epidural or spinal anesthesia for the management of pain in labor or delivery (when appropriate) and avoidance of narcotic agonist-antagonist drugs, such as butorphanol, nalbuphine, and pentazocine, as they may precipitate acute withdrawal .
Infants who have been exposed to opioids run a higher risk of developing NAS, which can appear 3 hours to 12 days after birth . NAS can also occur in infants exposed to nicotine and benzodiazepines in utero [25,33].
After delivery, the neonate should be assessed immediately for NAS, the signs of which are generally apparent with routine newborn assessment and Apgar scores. Apgar scores are based on assessment of five categories (heart rate, respiratory effort, muscle tone, reflex irritability, and color) and are administered to all infants regardless of opioid exposure; however, special attention should be paid to possible signs of withdrawal in exposed infants . The scores in each Apgar domain range from 0 to 2, with a maximum possible score of 10. The average score is 8 to 10, which indicates the infant does not need immediate attention. If the score is less than 8, the system affected is identified and appropriate medical procedures are initiated. If a third assessment at 10 minutes after birth does not show improvement, transfer to the NICU is warranted. Infants with acute NAS usually have an Apgar score less than 8; however, there have been instances in which an infant's Apgar score is within normal range at birth but then deteriorates and begins to show signs of NAS within 3 to 12 hours . Comparison studies have found no significant differences in Apgar scores at birth of infants exposed to buprenorphine compared to those exposed to methadone .
The signs of NAS are a result of the effects of opioid withdrawal on the infant's neurological, gastrointestinal, and autonomic systems . Neurologically, the clinical signs of NAS include irritability; staying awake for long periods of time/sleeping in short intervals; high-pitched crying and inconsolability; seizures; sneezing; stiff arms, legs, and back; and body tremors with or without a Moro reflex . NAS may also compromise the infant's gastrointestinal system, resulting in vomiting, diarrhea, dehydration, and inadequate weight gain. High fever is common, and regulating the body temperature can be difficult. Elevations in respiration and blood pressure can occur . Infants often appear uncomfortable and restless, even after being fed or swaddled.
If signs of NAS are present, the infant should be taken to the NICU for further assessment and to determine the amount of opioid replacement (e.g., morphine) necessary to stabilize the patient, reverse the syndrome, and reduce the complications of withdrawal, if indicated. Additional medications (e.g., phenobarbital for seizures) may be required to control symptoms.
Several assessment tools are available to help determine the severity of NAS, including the Finnegan Neonatal Abstinence Scoring System, the Lipsitz Neonatal Drug-Withdrawal Scoring System, the Neonatal Withdrawal Inventory, the Neonatal Narcotic Abstinence Scoring Index, and the Withdrawal Assessment Tool–Version 1 (WAT-1) [20,39]. The Finnegan Neonatal Abstinence Scoring System is a 31-item scale that will quantify the severity of NAS in order to help guide treatment decisions. The tool may be administered every four hours, and if an infant receives a score of 8 or more points, or the total for three consecutive scores is greater than 23, pharmacotherapy is indicated. The Lipsitz Neonatal Drug-Withdrawal Scoring System consists of 11 items, and a score of 4 or greater is an indication that opioid therapy should be started. The Neonatal Withdrawal Inventory is an 8-point checklist of NAS symptoms, with a 4-point behavioral distress scale . The Neonatal Narcotic Withdrawal Index is comprised of 6 items, for a possible maximum score of 12 points. A score of 5 or more on this index should prompt pharmacologic intervention . Finally, the WAT-1 is administered to infants experiencing NAS who have been exposed to opioids and benzodiazepines for an extended period of time (including throughout a pregnancy) . With this tool, pharmacotherapy is recommended for patients who score 10 or more points. However, the relative efficacy of these cut scores has not been definitively proven .
If indicated, opioid treatment should be initiated and the infant should be reassessed every three hours. Treatment with other sedatives (e.g., benzodiazepines, clonidine) has been effective, but 83% of physicians in the United States use an opioid (morphine or methadone) to treat NAS . The dose of replacement opioid varies according to the severity of symptoms and degree of exposure; the average initial dose of morphine is 0.05 mg/kg every three hours . If there is no improvement after three hours, the dose may be increased to 0.08 mg/kg, then again to a maximum of 0.1 mg/kg every four hours if necessary. Stabilization may take up to 48 hours. After 24 to 48 hours of a constant morphine dose, a gradual weaning can begin. Even after morphine is discontinued, the infant should be monitored hourly for 48 hours. If signs of NAS reappear, the original dose should be restarted and the same procedure followed until successful. After this, discharge plans may be implemented .
After NAS has resolved and the infant is stabilized, the interdisciplinary team, together with the mother or caregiver, should work to create a discharge plan that will be conducive to the health and safety of the infant and the mother. It is important that infants continue to be physically supported and monitored for any signs of digression.
Breastfeeding is highly recommended for all infants, even if the mother is continuing OMT . Some studies have shown that breastfeeding in these cases may reduce the need for withdrawal treatment in infants . According to the American Academy of Pediatrics, methadone is compatible with breastfeeding as long as the mother's intake does not exceed 20 mg in 24 hours [23,35]. A very small amount of methadone is transferred to the infant, but not enough to cause symptoms.
There is limited research on the effects of buprenorphine in breastfeeding mothers and their infants . Low levels of buprenorphine are passed to the infant during breastfeeding, and buprenorphine is excreted into breast milk for approximately two hours following the ingestion of the medication.
Overall, women who do not have health issues that could compromise the health of the infant or themselves should be encouraged to breastfeed their infants. Medical contradictions to breastfeeding include maternal HIV infection, active tuberculosis, continued use of illicit drugs, and some cancer treatments . In the past, hepatitis C was considered a contraindication to breastfeeding, but this is no longer the case .
Most infants with NAS are in the NICU for at least four days and up to more than 100 days, and it is important to ensure that the child is discharged to a stable home . The discharge plan should include the infant's pediatrician, who will have access to the infant's record and a knowledge of any pharmacotherapy given and the length of stay in the hospital. Along with the pediatrician, the plan should include other members of the interdisciplinary team, including the mother's obstetrician/gynecologist, social workers, chemical dependency counselors, and supportive family members or friends . The mother or caregiver should have a clear understanding of the aspects of caring for the child, especially if he or she was born with congenital abnormalities. The health and drug use of the mother or caregiver should also be properly assessed, either by an outpatient counselor or toxicology reports. A social worker will determine if the home environment is safe for the child and the mother. Studies have shown that mothers who were or are victims of intimate partner violence are more likely to have poor pregnancy outcomes and adverse neonatal outcomes, including infants born with NAS . In addition, opioid use during pregnancy, even if monitored, is a risk factor for continued or relapsed illicit use. Children who are exposed to their mother or father actively using drugs are more likely to experience family violence and impaired development, especially language . Drug exposure is also linked to poor nutrition, neglect, emotional instability, and environmental instability .
Congenital heart defects are a significant contributor to infant mortality, and early detection is vital . Evaluation with fetal echocardiography is indicated . Some infants exposed to opioids in utero will have heart defects, and an aftercare plan specific to the child's needs is required, including dietary plans, exercise recommendations, and regular visits to the cardiologist and the pediatrician.
Glaucoma is another possible outcome in infants exposed to opioids in utero. The discharge plan for these patients includes regular visits to an ophthalmologist and pediatrician to monitor the progression of the disease.
There is evidence that opioid exposure can affect fine and gross motor coordination in offspring. In addition, cognitive delays have been noted throughout childhood, manifesting as short or poor attention span, hyperactivity, learning disability, and delayed speech and language development [43,44]. A study by Konijnenberg and Melinder involving mothers who used OMT during pregnancy found that the mirror neuron system (MNS) was affected in infants exposed to opioids in utero . The MNS is a neural circuit that involves understanding social cues and interactions. The main area affected was visual input, which made watching another person and/or learning by visual cues for any length of time difficult. This study gives some insight into the mechanisms causing hyperactivity and short attention span when opioid-exposed offspring are in a structured environment (e.g., a school classroom) .
It is important that follow-up continue with these children through the school years. Language delay assessments can be administered by a speech language pathologist when the child is approximately 2 years of age. If indicated by the results, early intervention plans may be created and involve the parent/caregiver, speech language pathologist, occupational therapist, and pediatrician .
Opioid dependence involving pregnant women is an epidemic across the United States and abroad. It affects the future of infants and children in a variety of ways. As a result of in utero exposure to opioids, many infants develop NAS, with potentially disabling results if inadequately treated. Other possible complications of opioid exposure include congenital diseases, learning disabilities, behavior problems, and cognitive deficits. As such, it is necessary that every aspect of OMT and early recognition of pregnancy in women using opioids is explained thoroughly. Through research, education, prevention, and support from the medical and academic community, this epidemic will be managed properly and the lives of women and children will be saved.
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