Women with untreated substance use disorder during pregnancy have multiple and interacting risks that impact both maternal and fetal health. Understanding the complex issues in this group of patients is important for delivering the best care. Recent studies and position papers outline the scope of the issue, and provide guidelines for care.
Opioid use disorder among pregnant women rose sharply over the first 15 years of this century, according to the most comprehensive national survey to date, published in MMWR, the Morbidity and Mortality Weekly Report from the Centers for Disease Control and Prevention1. The rise coincided with the rise in opioid use more broadly during the same period, and indicates that pregnant women are not immune from the risks of prescription and illicit opioids.
Published in 2018, the study combined data from 28 states and the District of Columbia, culled from the National Inpatient Sample and State Inpatient Databases maintained by the Agency for Healthcare Research and Quality. Cases of opioid use disorder were identified by ICD-9-CM codes1.
The data showed that between 1999 and 2014 opioid use during pregnancy more than quadrupled, from 1.5 per 1000 to 6.5 per 1000 delivery hospitalizations. That average included some states where the rate barely changed (New Jersey, 4.1 to 5.0), and some where it skyrocketed (Vermont 0.5 to 43.7, West Virginia 0.6 to 21.3).1
The authors noted that the data are limited by differences in diagnostic procedures by state, and that “states with enhanced procedures for identifying infants with neonatal abstinence syndrome might ascertain more cases of maternal opioid use disorder.”1
They concluded, “Arranging for pregnant patients with opioid use disorder to deliver at facilities prepared to monitor and care for infants with neonatal abstinence syndrome can facilitate access to appropriate care. After delivery, women might need referrals to postpartum psychosocial support services, substance-use treatment, and relapse-prevention programs.… National, state, and provider efforts are needed to prevent, monitor, and treat opioid use disorder among reproductive-aged and pregnant women.”1
Recently, the American Society of Addiction Medicine issued a public policy statement on “Substance Use, Misuse, and Use Disorders During and Following Pregnancy, with an Emphasis on Opioids.” They note that substance use disorder (SUD) and withdrawal during pregnancy present risks for both mother and fetus. Overdose can kill both, while withdrawal “may threaten the viability of the fetus through an increased potential for spontaneous abortion.”2
Untreated SUD can lead to complications for mother, fetus, and child, including increased risk for sexually transmitted infections, poor nutrition, and poor prenatal care.
“For pregnant women with opioid use disorder, opioid agonist pharmacotherapy is the standard of care,” the authors write. The Society’s Practice Guideline recommends that “pregnant women who are physically dependent on opioids receive treatment using methadone or buprenorphine monoproduct rather than withdrawal management to abstinence.” Special attention to adequate pain control during delivery is needed and should be individualized. Breastfeeding should be encouraged, they note, “as both breastfeeding and skin-to-skin contact can reduce the severity and duration of neonatal abstinence syndrome.”2
Finally, they caution that evidence of substance use is not evidence of child endangerment, and that a positive urine drug test is not synonymous with impairment in ability to care for a child. “Sanctions against parents under child protective services interventions should be made only when there is objective evidence of danger, not simply evidence of substance use,” the authors stress.2
1Haight SC, Ko JY, Tong VT, Bohm MK, Callaghan WM. Opioid Use Disorder Documented at Delivery Hospitalization - United States, 1999-2014. MMWR Morb Mortal Wkly Rep. 2018 Aug 10; 67(31): 845–849. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6089335/
2American Society of Addiction Medicine (ASAM). Public Policy Statement on Substance Use, Misuse, and Use Disorders During and Following Pregnancy, with an Emphasis on Opioids. Adopted by the ASAM Board of Directors January 18, 2017. https://www.asam.org/docs/default-source/public-policy-statements/substance-use-misuse-and-use-disorders-during-and-following-pregnancy.pdf?sfvrsn=644978c2_4#search=%22pregnancy%22