Study Points

Management of Opioid Dependency During Pregnancy

Course #93092 - $15 • 2 Hours/Credits

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  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.
  1. Women are more likely than men to

    BIOLOGIC EFFECTS OF OPIOIDS

    Women between 25 and 54 years of age are most likely to be prescribed opioid pain medications, and 7 out of 10 prescription drug deaths among women involve opioids [4]. This may be due in part to the greater incidence of chronic pain syndromes in this patient population [5]. 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 [6]. Studies have shown that men and women experience different side effects and responses to analgesic medications, which may be influenced by physiologic differences and/or social and psychologic factors. 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 [7]. 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 [8].

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  2. Opioids share all of the following physiologic effects, EXCEPT:

    BIOLOGIC EFFECTS OF OPIOIDS

    Opioids are defined broadly as all compounds related to opium—both natural products and synthetic derivatives. Opioids affect many body systems and share the following physiologic effects [9,10,11]:

    • Analgesia

    • Changes in mood and reward behavior

    • Disruption of neuroendocrine function

    • Alteration of respiration

    • Changes in cardiovascular and gastrointestinal function

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  3. Which of the following is NOT a sign or symptom of opioid withdrawal?

    BIOLOGIC EFFECTS OF OPIOIDS

    Because many oral prescription opioids have half-lives of 24 to 36 hours, users often use at least daily to avoid withdrawal symptoms. Early symptoms and signs experienced during withdrawal include:

    • Confusion

    • Hallucinations

    • Delirium

    • Urticarial vasculitis

    • Hypothermia

    • Tachycardia

    • Orthostatic hypotension

    • Headache

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  4. Active use of opioids during pregnancy is associated with an increased risk for

    PREGNANCY IN PATIENTS TAKING OPIOIDS

    All patients taking opioids who can become pregnant 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 [18]. For pregnant patients, actively using opioids is associated with an increased risk for obstetric and gynecologic complications such as pre-eclampsia, communicable infections (e.g., hepatitis C, human immunodeficiency virus [HIV]), low-birth-weight infants, stillbirths, pre-eclampsia, excessive bleeding, miscarriages, small head circumference in offspring, preterm deliveries, and even death [19; 20].

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  5. Which of the following statements regarding the use of methadone for medication-assisted treatment (MAT) during pregnancy is TRUE?

    MEDICALLY MANAGED OPIOID DEPENDENCE 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 [17]. 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 [21].

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  6. The maximum daily dose of buprenorphine for MAT during pregnancy is

    MEDICALLY MANAGED OPIOID DEPENDENCE DURING PREGNANCY

    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) [29].

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  7. Which of the following congenital defects is more common among infants exposed to opioids in utero?

    MEDICALLY MANAGED OPIOID DEPENDENCE DURING PREGNANCY

    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]:

    • Spina bifida

    • Hydrocephaly

    • Glaucoma

    • Gastroschisis

    • Cleft palate

    • Congenital heart defects (e.g., conoventricular septal defect, hypoplastic left heart syndrome, atrial septal defect, tetralogy of Fallot, pulmonary valve stenosis)

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  8. Which of the following statements regarding neonatal abstinence syndrome (NAS) is TRUE?

    MEDICALLY MANAGED OPIOID DEPENDENCE DURING PREGNANCY

    Infants who have been exposed to opioids run a higher risk (30% to 80%) of developing NAS, which can appear within 72 hours to 14 days after birth for methadone (resolving in several days to weeks) and within 12 to 48 hours after birth for buprenorphine (peak: 72 to 96 hours; resolving in seven days) [22,25]. NAS can also occur or be exacerbated in infants exposed or co-exposed to nicotine, benzodiazepines, and/or selective serotonin reuptake inhibitors in utero [22,25,33].

    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 [18]. 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 [18]. Comparison studies have found no significant differences in Apgar scores at birth of infants exposed to buprenorphine compared to those exposed to methadone [34].

    The signs of NAS are a result of the effects of opioid withdrawal on the infant's neurologic, gastrointestinal, and autonomic systems [19]. 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 [20]. 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 [20]. Infants often appear uncomfortable and restless, even after being fed or swaddled.

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  9. All of the following statements regarding the treatment of NAS are true, EXCEPT:

    MEDICALLY MANAGED OPIOID DEPENDENCE DURING PREGNANCY

    Several assessment tools are available and recommended 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 Withdrawal Index, and the Withdrawal Assessment Tool–Version 1 (WAT-1) [20,22,39]. 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. In response to the complexity of the Finnegan tool, a shorter modified version is available (the Finnegan Neonatal Abstinence Syndrome Scale—Short Form) and is recommended by the American Academy of Pediatrics [37]. 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 [20]. The Neonatal Narcotic Withdrawal Index is comprised of six items, for a possible maximum score of 12 points. A score of 5 or more on this index should prompt pharmacologic intervention [20]. Finally, the WAT-1 is administered to infants experiencing NAS who have been exposed to opioids and benzodiazepines for an extended period (including throughout a pregnancy) [25]. With this tool, pharmacotherapy is recommended for patients who score 10 or more points. However, the relative efficacy of these scores has not been definitively proven [35].

    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 [35]. The dose of replacement opioid varies according to the severity of symptoms and degree of exposure; the average initial dose of morphine sulfate is 0.05 mg/kg every three hours [36]. 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 [37].

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  10. Children who are exposed to their mother or father actively using drugs are more likely to experience

    MEDICALLY MANAGED OPIOID DEPENDENCE DURING PREGNANCY

    Most infants with NAS are in the NICU for an average of 19 days (range: 7 to 32 days), and it is important to ensure that the child is discharged to a stable home [41]. It should be noted that infants who remain in the same room as their mothers have shorter length of stays and are more likely to be discharged home [37]. 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 [23]. 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 [42]. 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 [43]. Drug exposure is also linked to poor nutrition, neglect, emotional instability, and environmental instability [44].

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  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.