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Turner S, Allen VM, Carson G, Graves L, Tanguay R, Green CR, Cook JL. Guideline No. 443b: Opioid Use Throughout Women's Lifespan: Opioid Use in Pregnancy and Breastfeeding. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102144. [PMID: 37977721 DOI: 10.1016/j.jogc.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
OBJECTIVE To provide health care providers the best evidence on opioid use and women's health. Areas of focus include pregnancy and postpartum care. TARGET POPULATION The target population includes all women currently using or contemplating using opioids. OUTCOMES Open, evidence-informed dialogue about opioid use will improve patient care. BENEFITS, HARMS, AND COSTS Exploring opioid use through a trauma-informed approach provides the health care provider and patient with an opportunity to build a strong, collaborative, and therapeutic alliance. This alliance empowers women to make informed choices about their own care. It also allows for the diagnosis and possible treatment of opioid use disorders. Opioid use should not be stigmatized, as stigma leads to poor "partnered care" (i.e., the partnership between the patient and care provider). Health care providers need to understand the effect opioids can have on pregnant women and support them to make knowledgeable decisions about their health. EVIDENCE A literature search was designed and carried out in PubMed and the Cochrane Library databases from August 2018 until March 2023 using following MeSH terms and keywords (and variants): opioids, opioid agonist therapy, illicit drugs, fertility, pregnancy, fetal development, neonatal abstinence syndrome, and breastfeeding. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE All health care providers who care for pregnant and/or post-partum women and their newborns. TWEETABLE ABSTRACT Opioid use during pregnancy often co-occurs with mental health issues and is associated with adverse maternal, fetal, and neonatal outcomes; treatment of opioid use disorder with agonist therapy for pregnant women can be safe during pregnancy where the risks outnumber the benefits. SUMMARY STATEMENTS RECOMMENDATIONS.
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Turner S, Allen VM, Carson G, Graves L, Tanguay R, Green CR, Cook JL. Directive clinique n o 443b : Opioïdes aux différentes étapes de la vie des femmes : Grossesse et allaitement. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102146. [PMID: 37977719 DOI: 10.1016/j.jogc.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
OBJECTIF Présenter aux professionnels de la santé les données probantes concernant l'utilisation des opioïdes et la santé des femmes. Les domaines d'intérêt sont la grossesse et les soins post-partum. POPULATION CIBLE Toutes les femmes qui utilisent des opioïdes. RéSULTATS: Un dialogue ouvert et éclairé sur l'utilisation des opioïdes améliorera les soins aux patientes. BéNéFICES, RISQUES ET COûTS: L'exploration de l'utilisation d'opioïdes par une approche tenant compte des traumatismes antérieurs donne au professionnel de la santé et à la patiente l'occasion de bâtir une alliance solide, collaborative et thérapeutique. Cette alliance permet aux femmes de faire des choix éclairés. Elle favorise le diagnostic et le traitement possible du trouble lié à l'utilisation d'opioïdes. L'utilisation ne doit pas être stigmatisée, puisque la stigmatisation affaiblit le partenariat (le partenariat entre patiente et professionnel de la santé). Les professionnels de la santé ceus-ci doivent comprendre l'effet potentiel des opioïdes sur la santé les femmes enceintes et les aider à prendre des décisions éclairées sur leur santé. DONNéES PROBANTES: Une recherche a été conçue puis effectuée dans les bases de données PubMed et Cochrane Library pour la période d'août 2018 à mars 2023 des termes MeSH et mots clés suivants (et variantes) : opioids, opioid agonist therapy, illicit drugs, fertility, pregnancy, fetal development, neonatal abstinence syndrome et breastfeeding. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: Tous les professionnels de la santé qui prodiguent des soins aux femmes et aux nouveaux-nés. RéSUMé POUR TWITTER: La consommation d'opioïdes pendant la grossesse coïncide souvent avec des problèmes de santé mentale et est associée à des conséquences néfastes pour la mère, le fœtus et le nouveau-né ; le traitement des troubles liés à la consommation d'opioïdes par agonistes peut être sûr pendant la grossesse lorsque les risques sont plus nombreux que les avantages. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.
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Clark RS, Pares-Avila JA. A Pathway to Treatment for Pregnant Women With Opioid Use Disorder. J Addict Nurs 2023; 34:173-177. [PMID: 37669336 DOI: 10.1097/jan.0000000000000537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
BACKGROUND Addiction to opioids, a well-known public health crisis, is now more prevalent in pregnant women as evidenced by the parallel rise with pregnant women in the epidemic with the general population. Evidence is now available that substantiates the need for global awareness to increase efforts in the treatment of pregnant women with opioid use disorder (OUD) as this vulnerable population lacks equal access to opioid abuse treatment across the United States. AIM The overarching aim and purpose of this quality improvement project was to increase access to treatment for pregnant women with OUD who are currently underserved in a community located in Florida. METHODS Between January and April 2022, the 4Ps (parents, partners, past, and pregnancy), a validated screening tool, was implemented in an organization that accepts individuals with substance abuse. Each positive screen was referred for assessment for buprenorphine induction and medication-assisted treatment follow-up. Descriptive statistics were collected counting the number of screens completed, the number of positive screens, the number of referrals, and the number of patients remaining in treatment for 30 and 60 days. RESULTS Twenty-two screens were completed. The results yielded an increase in referrals, a 75% increase in treatment of pregnant women, and an average of 83% of participants remained in treatment. CONCLUSION The implementation of a validated screening tool assisted in increasing access to treatment for pregnant women with OUD. Once implemented, the screening tool forges a pathway for referrals and evidence-based treatment for pregnant women with OUD.
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Affiliation(s)
- Roshunya Shavon Clark
- Roshunya Shavon Clark, DNP, APRN, AGNP-C, and Jose A. Pares-Avila, DNP, MA, ANP-C, APRN, LMHC, FAANP, College of Nursing, University of South Florida, Tampa
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Lim G, Soens M, Wanaselja A, Chyan A, Carvalho B, Landau R, George RB, Klem ML, Osmundson SS, Krans EE, Terplan M, Bateman BT. 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. Anesth Analg 2022; 135:912-925. [PMID: 36135926 PMCID: PMC9588509 DOI: 10.1213/ane.0000000000006167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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.
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Affiliation(s)
- Grace Lim
- University of Pittsburgh Department of Anesthesiology & Perioperative Medicine, Pittsburgh, PA
- University of Pittsburgh Department of Obstetrics & Gynecology, UPMC Magee-Women’s Hospital, Pittsburgh, PA
| | - Mieke Soens
- Brigham & Women’s Hospital, Department of Anesthesiology & Perioperative Medicine, Boston, MA
| | - Anne Wanaselja
- University of Pittsburgh Department of Anesthesiology & Perioperative Medicine, Pittsburgh, PA
| | - Arthur Chyan
- Brigham & Women’s Hospital, Department of Anesthesiology & Perioperative Medicine, Boston, MA
| | - Brendan Carvalho
- Stanford University Department of Anesthesiology, Perioperative & Pain Medicine, Palo Alto, CA
| | - Ruth Landau
- Columbia University Department of Anesthesiology & Perioperative Medicine, New York City, NY
| | - Ronald B. George
- University of California San Francisco Department of Anesthesiology & Perioperative Care, San Francisco, CA
| | - Mary Lou Klem
- University of Pittsburgh Health Sciences Library System, Pittsburgh, PA
| | - Sarah S. Osmundson
- Vanderbilt University, Department of Obstetrics & Gynecology, Nashville, TN
| | - Elizabeth E. Krans
- University of Pittsburgh Department of Obstetrics & Gynecology, UPMC Magee-Women’s Hospital, Pittsburgh, PA
| | | | - Brian T. Bateman
- Stanford University Department of Anesthesiology, Perioperative & Pain Medicine, Palo Alto, CA
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Abstract
PURPOSE OF REVIEW Opioid use disorder (OUD) in pregnancy has more than quadrupled in prevalence over the past two decades and continues to increase steadily every year. With no defined standard of care for the management of pain during the peripartum period, variability in treatment plans potentially leaves room for interrupted patient care, decreased patient satisfaction, and poorer outcomes. The impact of OUD and its management during the peripartum period has become more widely discussed over the past several years and is the focus of this review. RECENT FINDINGS Current recommendations including developing a detailed institutional plan for the management of pain for women with OUD during the intrapartum and postpartum periods. There is tremendous value in exploring partnerships with other specialties, including addiction medicine, and behavioral health and obstetrics in development of policies and procedures. Consistency within institutions is critical to improve patient outcomes. SUMMARY This review will address both pain management recommendations and best clinical practices regarding management of the parturient during the transition periods of the peripartum, intrapartum, and postpartum period. Novel approaches and perspectives from case reports and narrative experience will also be discussed. There are many opportunities in this field for further studies, research, and evidence-based guidelines that promote an established standard of care.
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Reno JL, Kushelev M, Coffman JH, Prasad MR, Meyer AM, Carpenter KM, Palettas MS, Coffman JC. Post-Cesarean Delivery Analgesic Outcomes in Patients Maintained on Methadone and Buprenorphine: A Retrospective Investigation. J Pain Res 2021; 13:3513-3524. [PMID: 33408510 PMCID: PMC7779306 DOI: 10.2147/jpr.s284874] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/03/2020] [Indexed: 12/30/2022] Open
Abstract
Background Despite the increasing prevalence of opioid use disorder (OUD) in pregnant women, there are limited studies on their anesthesia care and analgesic outcomes after cesarean delivery (CD). Methods Patients with OUD on either buprenorphine or methadone maintenance therapy who underwent CD at our institution from 2011 to 2018 were identified. Anesthetic details and analgesic outcomes, including daily opioid consumption and pain scores, were compared between patients maintained on buprenorphine and methadone. Analgesic outcomes were also evaluated according to anesthetic type (neuraxial or general anesthesia) and daily buprenorphine/methadone dose to determine if these factors impacted pain after delivery. Results A total of 146 patients were included (buprenorphine n=99 (67.8%), methadone n=47 (32.2%)). Among all patients: 74% had spinal/CSE, 15% epidural, and 11% general anesthesia. Anesthesia types were similar among buprenorphine and methadone patients. For spinal anesthetics, intrathecal fentanyl (median 15 µg) and morphine (median 100 µg) were commonly given (97.2% and 96.3%, respectively), and dosed similarly between groups. Among epidural anesthetics, epidural morphine (median 2 mg) was commonly administered (90.9%), while fentanyl (median 100 µg) was less common (54.5%). Buprenorphine and methadone groups consumed similar amounts of oxycodone equivalents per 24 hours of hospitalization (80.6 vs 76.3 mg; p=0.694) and had similar peak pain scores (8.3 vs 8.0; p=0.518). Daily methadone dose correlated weakly with opioid consumption (R=0.3; p=0.03), although buprenorphine dose did not correlate with opioid consumption or pain scores. General anesthesia correlated with greater oxycodone consumption in the first 24 hours (median 156.1 vs 91.7 mg; p=0.004) and greater IV PCA use (63% vs 7%; p<0.001) compared to neuraxial anesthesia. Conclusion Patients on buprenorphine and methadone had similar high opioid consumption and pain scores after CD. The anesthetic details and analgesic outcomes reported in this investigation may serve as a useful reference for future prospective investigations and aid in the clinical care of these patients.
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Affiliation(s)
- Joseph L Reno
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Michael Kushelev
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, USA
| | - Julie H Coffman
- Department of Internal Medicine, Riverside Methodist Hospital, Columbus, OH, USA
| | | | - Avery M Meyer
- Department of Psychiatry and Behavioral Health, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kristen M Carpenter
- Department of Psychiatry and Behavioral Health, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - John C Coffman
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, USA
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Magnetic molecularly imprinted polymer nanoparticles for dispersive micro solid-phase extraction and determination of buprenorphine in human urine samples by HPLC-FL. JOURNAL OF THE IRANIAN CHEMICAL SOCIETY 2018. [DOI: 10.1007/s13738-018-1355-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Abstract
Opioid use disorder presents an increased risk of complications in pregnancy, particularly when untreated. To optimize outcomes, medication-assisted treatment using methadone or buprenorphine as a part of a comprehensive care model is recommended. Neonatal abstinence syndrome and poor fetal growth remain significant complications of this disorder despite maternal treatment.
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Affiliation(s)
- Amanda J Johnson
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Cresta W Jones
- Department of Obstetrics, Gynecology and Women's Health, Division of Maternal-Fetal Medicine, University of Minnesota Medical School, 606 24th Avenue S, Suite 400, Minneapolis, MN 55455, USA.
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