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.
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]: http://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.
METHODS
The reporting of this scoping review was guided by the Preferred Reporting Items for Systemic Reviews and Meta-Analysis extension for Scoping Review standards (PRISMA-ScR).6 A working group from the Society for Obstetric Anesthesia and Perinatology (SOAP) defined, by consensus, specific key questions that would be important for peripartum pain management in pregnant people with OUD, both treated with MOUD or untreated (Supplemental Digital Content 1, Appendix 1, https://links.lww.com/AA/E11). Questions were developed to comprehensively capture all relevant clinical decision-making points before, during, and after labor and delivery. Two investigators (G.L. and M.S.) used these questions to identify and saturate on themes of topics that are of interest to pain management in pregnant people with OUD. These questions were considered for each of the following populations: (1) pregnant people receiving MOUD for whom OUD was due to an acute or chronic pain condition; (2) pregnant people receiving MOUD for whom OUD was not due to pain condition; (3) pregnant people with untreated OUD; and (4) pregnant people with OUD who are stable in recovery and not receiving MOUD.
Methodology and Sources
The databases PubMed and Embase were systematically searched from inception until March 31, 2020, for published journal articles. PubMed covers the health care literature where most peer-reviewed publications are indexed. Embase covers European, North American, and other non-North American literature. An experienced health sciences librarian (C.B.W.) designed the PubMed search, which was then translated for use in Embase.com by a second health sciences librarian (M.L.K.). For both databases, a search string was developed using both controlled vocabulary terms (eg, Medical Subject Headings [MeSH] terms) and natural language informed by a subject matter expert (G.L.) to represent the concepts of OUD, peripartum pain, and pain management (Supplemental Digital Content 2, Appendix 2, https://links.lww.com/AA/E12).
The results of the database searches were downloaded to an EndNote library, and duplicate records were removed by a health sciences librarian (M.L.K.) using a process developed by Bramer et al.7 Covidence systematic review software (Veritas Health Innovation) was used to manage citations and track ratings.
Inclusion/Exclusion Criteria
Articles included labor and delivery pain management for vaginal delivery, postpartum pain management for vaginal delivery, and postpartum pain management for cesarean delivery. Articles were included if they were original research, case studies, case series, or cohort studies, letters to the editor, commentaries, white papers, published abstracts, or review articles. All languages were included, with non-English articles translated by certified medical translator services to English, the authors’ primary language.
Study Selection
Article titles and abstracts were screened and included if they contained the following terms: pain, analgesia, or pain management; pregnancy, parturient, or perinatal; labor and delivery, intrapartum, or cesarean delivery or postpartum; OUD with MOUD, OUD without MOUD, or substance use disorder with OUD specified in the title or abstract. Articles were excluded if they pertained to acute or chronic pain not in the peripartum period, or if they were nonhuman or animal studies. Two reviewers independently screened titles and available abstracts using the above predetermined inclusion/exclusion criteria and key questions from Supplemental Digital Content 1, Appendix 1, https://links.lww.com/AA/E11 (A.C. and A.W.). Duplicate abstracts were removed from consideration. Discrepancies between the 2 abstract reviewers were resolved through discussion; for persistent discrepancies requiring a tiebreaker, a third party (G.L.) was consulted. Cohen’s kappa statistic was calculated to evaluate interrater reliability between the 2 initial raters for this level of review. Full text for these studies was then located and reviewed; if duplicates were detected by full text, they were removed, as were studies that were deemed to be irrelevant and studies in which full text could not be located. Two reviewers independently screened full text (A.C. and A.W.), with discrepancies resolved through discussion and persistent discrepancies resolved through a third-party tie breaker (G.L.).
Extraction/Charting the Results
For abstracts that met the inclusion/exclusion criteria, full-text articles were then reviewed. Each article was then individually reviewed by G.L. using the prespecified relevance criteria established by the key questions in Supplemental Digital Content 1, Appendix 1, https://links.lww.com/AA/E11. Each article was associated with one or more codes corresponding to the relevant key questions in the 3 primary peripartum phases: immediate predelivery optimization, management of labor pain, and postcesarean delivery pain management. Study characteristics, including first author, language of original publication, year, journal, journal type (eg, anesthesiology, pain management, addiction medicine, obstetrics/gynecology, etc), methodology, sample size, study objective, and salient findings, were summarized (Supplemental Digital Content 3, Appendix 3, https://links.lww.com/AA/E13).
RESULTS
The database searches yielded 994 publications for review (PubMed = 473 and Embase = 521). A PRISMA flow diagram for study screening and eligibility assessment is shown in Figure 1. Nineteen duplicate abstracts were removed, and 975 titles and abstracts were screened, with 884 screened as irrelevant with 6 resolved discrepancies (moderate interrater reliability κ = 0.57). There were then 91 full-text studies reviewed and assessed for eligibility, with 7 removed (duplicates, irrelevant, or unable to locate full text). There were 2 publications originally written in non-English (German and French). The final list included 84 full-text publications for complete review.
Question | Guideline | Systematic review | Narrative review | Randomized trial | Cohort study | Case control/case series/case reports | Opinion |
---|---|---|---|---|---|---|---|
Predelivery pain management optimization | |||||||
1. What comorbidities are associated with OUD that can affect peripartum pain management (anxiety, depression, and chronic pain)? | Jones et al 8 | Korket al 9 | Ordeanet al 13 | Cengiz et al 16 | Jones et al 18 | ||
Martin et al 10 | Gomar et al 17 | ||||||
Smith et al 14 | |||||||
Park et al 11 | Towers et al 15 | ||||||
Eyler 12 | |||||||
2. What comorbidsubstance use/abuse disorders are associated with OUD that can affect peripartum pain management (smoking and benzodiazepines)? | Martin et al 10 | Hoflich et al 19 | Birnbach et al 20 | Tabi et al 24 | |||
Eyler 12 | |||||||
McCalla et al 21 | |||||||
Robertson et al 22 | |||||||
Schulman et al 23 | |||||||
Ordean et al 13 | |||||||
3. Should all patients with OUD have a predeliveryanesthesia consult? | Wong et al 25 | Soens et al 26 | Cassidy and Cyna 28 | Eckeret al 30 | |||
Wilder and Winhusen 27 | Reddi et al 31 | ||||||
Wiegand et al 29 | |||||||
4. Predelivery medication management: methadone | Jones et al 8 | Brown 32 | Jones et al 49 | Ko et al 51 | Harter 54 | Jones and Terplan 56 | |
Faitot et al 33 | McNicholas et al 50 a | Meyer et al 52 | Kliman 55 | ||||
a. For planned vaginal delivery, should the dose be continued, increased, reduced, or stopped in anticipation of the delivery admission? | Wendling et al 53 | ||||||
Fultz 34 | |||||||
Wong et al 25 | Goff and O’Connor 35 | Ecker et al 30 | |||||
Wiegand et al 29 | |||||||
Gopman 36 | |||||||
Ordean et al 13 | |||||||
b. For planned cesarean delivery, should the dose be continued, increased, reduced, or stopped in anticipation of the delivery admission? | Jones 2012 37 | ||||||
Klaman et al 38 | |||||||
Ludlow et al 39 | |||||||
Lugo et al 40 | |||||||
Mahoney et al 41 | |||||||
Mozurkewichand Rayburn 42 | |||||||
Pan and Zakowski 43 | |||||||
Prithamand McKay 44 | |||||||
Raymond et al 45 | |||||||
Sen et al 46 | |||||||
Tran et al 47 | |||||||
Young et al 48 | |||||||
Park et al 11 | |||||||
Soens et al 26 | |||||||
Wilder and Winhusen 27 | |||||||
Martin et al 10 | |||||||
5. Predelivery medication management: buprenorphine | Jones et al 8 | Jones et al 57 | Jones et al 49 | Krans et al 62 | Leighton and Crock 64 | ACOG committee opinion 1 | |
Safleyand Swietlikowski 58 | McNicholas et al 50 a | Tith et al 63 | |||||
Meyer et al 65 | |||||||
Wendling et al 53 | Mittaland Suzuki 66 | ||||||
a. For planned vaginal delivery, should the dose be continued, increased, reduced, or stopped in anticipation of the delivery admission? | |||||||
Stanhope et al 59 | Wiegandet al 29 | Harter 54 | |||||
Ecker et al 30 | |||||||
Brown 32 | |||||||
Faitot et al 33 | |||||||
Gopman 36 | |||||||
Jones et al 4 | |||||||
Landau 60 | |||||||
b. For planned cesarean delivery, should the dose be continued, increased, reduced, or stopped in anticipation of the delivery admission? | Ludlow et al 61 | ||||||
Mahoney et al 41 | |||||||
Mozurkewich and Rayburn 42 | |||||||
c. If continued, should the dose of buprenorphine be split? | |||||||
Pan and Zakowski 43 | |||||||
Prithamand McKay 44 | |||||||
Raymond et al 45 | |||||||
Sen et al 46 | |||||||
Tran et al 47 | |||||||
Young et al 48 | |||||||
Park et al 11 | |||||||
Soens et al 26 | |||||||
Wilder and Winhusen 27 | |||||||
Martin et al 10 | |||||||
6. Predelivery medication management: naltrexone | Stanhope 2013 59 | ACOG Committee opinion 1 | |||||
Tran 2017 47 | |||||||
a. For planned vaginal delivery, should the medication be continued or stopped in anticipation of the delivery admission? | |||||||
b. For planned cesarean delivery, should the medication be continued or stopped in anticipation of the delivery admission? | |||||||
c. If stopped, at what stage of pregnancy? | |||||||
Pain management in labor and delivery | |||||||
1. Is there evidence for increased pain, analgesia dose requirement or increased use of analgesia during labor for patients on OUD treatment, including methadone, buprenorphine, and naltrexone? | Souzdalnitski and Snegovskikh 5 | Kuczkowski 67 | Ludlow et al 39 | Thakrar et al 71 | Jones and Terplan 56 | ||
Wolman et al 68 | Sander and Hays 69 | ||||||
Fultz and Senay 34 | Ellis et al 70 | ||||||
Wiegand et al 29 | |||||||
2. Is there any evidence that the response to neuraxial opioids may be altered (less effective) in patients on buprenorphine? | Kuczkowski 67 | Gupta et al 72 | |||||
3. Neuraxial | Pan and Zakowski 43 | Martin et al 73 | Hoyt et al 74 | Ecker et al 30 | |||
a. Should early epidural analgesia be recommended for patients with OUD? | Silver et al 75 | ||||||
Soens et al 26 | |||||||
b. Should opioids in the epidural solution be increased, decreased, or omitted? | |||||||
c. Should the concentration of the local anesthetic be increased? | |||||||
d. Should nonopioid adjuvants be added to the epidural solution, including clonidine, epinephrine, dexmedetomidine, and/or neostigmine? | |||||||
4. If the patient with OUD is not a candidate for neuraxial analgesia, is there a role for the following: | Faitot et al 33 | Migliaccio et al 76 | Ecker et al 30 | ||||
a. Nitrous oxide? | |||||||
b. IV opioid PCA? (If PCA is used, is there a particular opioid that is optimal?) | |||||||
c. Ketamine? | |||||||
d. Dexmedetomidine? | |||||||
e. Other adjuvants? | |||||||
f. How do narcotic analgesic alternatives interact with MOUD management goals? | |||||||
Soens et al 26 | |||||||
5. Treatment of postvaginal delivery pain | |||||||
a. If the patient has a high-order vaginal laceration, should long-actingopioids be administered through an indwelling epidural catheter? If so, what doses are recommended? | |||||||
b. Should NSAIDs be used? | |||||||
c. Should acetaminophen be used? | |||||||
d. Is there a role for the routine use of oral opioidsinhospital or at discharge? | |||||||
e. What is the role for other adjuvants for the treatment of postvaginal delivery pain? | |||||||
6. Withdrawal | Wolman et al 68 | ||||||
a. If a patient with OUD experiences withdrawal during labor, how should it be treated? | |||||||
b. What are the potential interactions between MOUD and partial antagonists (eg, nalbuphine and butorphanol)?How should opioid-inducedintrapartum itching be managed in a patient on buprenorphine? | |||||||
7. Monitoring | |||||||
a. Do patients with OUD require additional monitoring during or after labor? | |||||||
Postcesarean delivery pain management | |||||||
1. Should history of OUD impact the planned mode of delivery (cesarean versus vaginal delivery)? | Eyler 12 | ||||||
2. Is there evidence for increased pain and analgesia intake after cesareandelivery for patients on OUD treatment, including methadone, buprenorphine, and naltrexone? | Eyler 12 | Ellis et al 70 | Jones et al 80 | Jones et al 8 | |||
Shainker et al 77 | Parad et al 78 | ||||||
Vilkins et al 79 | |||||||
Meyer et al 65 | |||||||
Meyer et al 52 | |||||||
Wendling et al 53 | |||||||
3. Neuraxialanesthesia | |||||||
a. Should the usual dose of neuraxial opioids be increased, decreased, or should they be omitted? | |||||||
b. Should nonopioid adjuvants be added to the neuraxialanesthetic, including clonidine, epinephrine, dexmedetomidine, and/or neostigmine? | |||||||
c. Is there any evidence to suggest superiority of any specific nonopioid neuraxial adjuvant? | |||||||
4. Postcesareandelivery pain management | Brown 32 | Duzyj et al 81 | Kunycky 82 | Stanislaus et al 84 | Wasiluk et al 85 | ||
Jones et al 80 | |||||||
Leighton and Crock 64 | |||||||
Vilkins et al 83 | |||||||
a. What is the role for continuing neuraxial analgesia into the postpartum period? | |||||||
b. Should NSAIDs be used? | |||||||
c. Should acetaminophen be used? | |||||||
d. Is there a role for the routine use of oral opioidsin hospital? | |||||||
e. Are there special considerations regarding the type, dose, and quantity? | |||||||
f. Is there a role for the routine use of oral opioids at discharge? | |||||||
g. Are there special considerations regarding the type, dose, and quantity? | |||||||
h. What type of follow-up should be provided? | |||||||
i. What is the role for other adjuvants for the treatment of postcesarean pain? | |||||||
j. What is the role for regional anesthesia options, such as TAP, ESP, and QLB blocks, or continuous wound infiltration? Is any option more effective? | |||||||
k. What is the role for psychotherapeutic or behavioral interventions (eg, cognitive behavioral therapy) to address postcesarean pain? | |||||||
5. Management of neuraxial opioid-induced side effects and complications in the patient on buprenorphine | |||||||
a. How should itching be managed (Nalbuphine? Dose?) | |||||||
b. How should respiratory depression be managed (Naloxone? Dose?) | |||||||
c. Is morphine-induced hypothermia more common in patients on buprenorphine? How should it be managed? | |||||||
6. Monitoring | |||||||
a. Do patients with OUD require additional monitoring during or after cesarean delivery? |
Studies corresponding to the primary questions are shown in the Table, and study characteristics and details are shown in Supplemental Digital Content 3, Appendix 3, https://links.lww.com/AA/E13. One article was translated from German, and another was translated from French. Only 5 randomized trials (5.9%) and one systematic review (1.2%) were published in the study period. Most articles (n = 32; 38.1%) were published in obstetrics, gynecology, or perinatology journals, followed by anesthesiology (n = 22; 26.2%) and addiction medicine journals (n = 16; 19%; Figure 2). Peer-reviewed publications on peripartum pain management in pregnant people with OUD have steadily increased in volume over time (Figure 2), with most publications encompassing narrative review articles, retrospective cohort studies, and case reports or series (Figure 3).
Publications on Predelivery Pain Management Optimization
Most of the publications on predelivery pain management optimization for pregnant people with OUD consist of review articles, followed by retrospective chart reviews.1,8–15,19–31 Highlights include 6 case reports and series, 3 prospective observational studies, 2 guidelines, 1 randomized trial, and 1 committee opinion. Available evidence to guide medical care as it relates to pain management is notably limited.
The one randomized trial of 18 participants comparing pregnant people receiving methadone to those receiving buprenorphine found that after vaginal delivery, those treated with either buprenorphine or methadone reported adequate pain control (based on pain score ratings) with opioids and ibuprofen (main effect for medication group F[1, 19.3] = 0.01; P > .9).49 The methadone group used more ibuprofen postpartum (buprenorphine group decreased average ibuprofen use from 1725 to 1575 mg on average over postpartum days 1–5, during which the methadone group increased ibuprofen use from 1740 to 2040 mg on average). Another study investigated differences in pain management and analgesic medication use in 40 people receiving methadone or buprenorphine during pregnancy, matched to 80 nonopioid exposed pregnant people.19 After cesarean delivery, people with MOUD received fewer opioid analgesics (day of delivery, P = .03; day 1, P = .02), and nonsteroidal anti-inflammatory drugs (NSAIDs) were administered more frequently during surgery (MOUD group: 8/19 [42.1%]; comparison group: 4/38 [10.5%]; P = .006) and on postpartum day 3 (MOUD group: 10/19 [52.6%], comparison group: 9/38 [23.7%]; P = .029). Smoking status was an independent predictor of altered pain experience and had a strong influence on results in the MOUD group. Many currently available publications recommend continuing methadone and buprenorphine therapy throughout pregnancy and labor and delivery, rather than reducing or stopping the medication. These recommendations are primarily based on expert opinion that focused on chronic disease management throughout pregnancy86 rather than management of anticipated pain in labor and delivery. Most publications conclude that a multidisciplinary approach to patient management is necessary, with some recommending prenatal anesthesia consultation as part of that management.
Publications on Pain Management in Labor and Delivery
Articles on pain management in labor and delivery for people with OUD primarily included reviews, clinical opinions, case vignettes, retrospective studies, and a systematic review.5,29,34,39,56,67–71,87 The largest study on labor pain and labor analgesia in pregnant people with OUD was a retrospective chart review of 141 cases, published in 2004, that aimed to identify obstetric and perinatal outcomes in people using opioids (n = 91) or amphetamines (n = 50) during pregnancy; the epidural labor analgesia rate was 77%,39 and pharmacologic analgesia was used more often for labor and delivery (opioids, P = .007; amphetamines, P = .042). The possibility for return to use if opioids were used for labor analgesia was postulated by the authors of a 2014 systematic review, who emphasized the need for “good” labor analgesia because inadequate analgesia can instigate postpartum addiction recurrence and return to use.5 The authors suggested that to achieve good labor analgesia, neuraxial (not systemic) opioid doses need to be doubled or tripled in pregnant people with OUD,5 although these authors acknowledge the lack of available scientific data to guide appropriate dosing. Most published papers describe higher doses of opioids, if used, during labor and postpartum, due to the distinct phenomena of opioid tolerance and opioid-induced hyperalgesia. However, published opinions are conflicting on whether to use or to avoid systemic opioids. Opinions conflict due to concerns about risk for return to substance use that can be associated with exposure to systemic opioids (used for analgesia), as well as with poor pain control (which may result from avoidance of opioids).
Most publications, including the American College of Obstetricians and Gynecologists (ACOG) committee opinion,1 do not recommend medically supervised withdrawal during pregnancy, labor, and delivery. Comprehensive, multidisciplinary, individualized care planning—including chaplains, psychosocial services, and addiction medicine specialists—should be undertaken to optimize outcomes.5,71 Medically supervised withdrawal in pregnancy, labor, and delivery is not recommended over MOUD due to high return to opioid use rates (59%–90%), low detoxification completion rates, and limited data on maternal and neonatal outcomes beyond delivery.1 However, the lack of long-term outcomes and safe methods for medically supervised withdrawal in pregnancy or delivery urges more research to identify appropriate cases for which medically supervised withdrawal could be a noninferior and safe option in patients wishing to avoid medication during pregnancy.
Publications on Postcesarean Delivery Pain Management
Articles on postcesarean delivery pain management in pregnant people with OUD primarily include reviews, clinical opinions, letters to the editor, case series, and retrospective studies.32,52,53,65,70,77,80,82,83 Studies have been conflicting on whether people receiving MOUD experience increased pain after cesarean delivery and use higher doses of pain medication. One retrospective study found that opioid-naïve patients report lower pain scores and use fewer morphine equivalents than pregnant people receiving MOUD, with no differences between patients maintained receiving buprenorphine or methadone.53 In contrast, some studies have found evidence for increased pain and analgesia requirements after cesarean delivery for patients receiving MOUD. Retrospective studies found that patients receiving methadone and buprenorphine receive 70% and 47% more opioid medications for pain management after cesarean delivery, respectively, compared to no opioid maintenance.52,65,77 A quality improvement project assessed adherence to a protocol for postoperative pain control in patients with MOUD, and found that only 41% received the treatment protocol.82 Efforts are needed not only to design, but also to reliably implement, systems-based solutions for pain management in patients receiving MOUD.
Available publications are conflicting with respect to use or avoidance of opioids for postpartum pain management in patients with OUD. A case series reported on continuing MOUD (buprenorphine or methadone) after cesarean delivery, adding scheduled NSAIDs and acetaminophen after delivery, and described oral opioid use for breakthrough pain, which was effective in reducing pain.80 However, the authors caution on the potential need for higher than typical doses of opioids, although the data to support this conclusion were not provided. A retrospective study assessed postcesarean opioid analgesic requirements in people with MOUD (methadone or buprenorphine) and found that buprenorphine-treated patients had fewer opioid requirements than those treated with methadone.83 Articles advocating avoidance of opioids after cesarean delivery cite risk for misuse, return to use, and overdose. One retrospective study of 72 subjects found that 75% of people with OUD received opioid medications at discharge after delivery; in regression analysis, receiving opioids at discharge (β, 1.35; SE, 1.22; P = .041) and having a cesarean delivery (β, 1.27; SE, 0.97; P = .043) were associated with higher odds of opioid misuse within the first 30 days after delivery.70 Another review article made explicit recommendations that no opioids should be used in the perioperative period, although the evidence to support this statement was not provided.32
There is no published evidence on social support or psychotherapy for pain management after cesarean delivery in patients with OUD. There were no identified articles on monitoring that could help answer questions on whether patients with OUD should require additional monitoring during or after cesarean delivery. No available published articles answer specific questions about pain management for patients receiving MOUD related to various preexisting pain conditions, patients with untreated OUD, and patients with OUD who are currently abstaining from opioids. There are no published articles that address the utility of abdominal wall blocks such as continuous wound infiltration (CWI), transversus abdominis plane (TAP), or quadratus lumborum (QL) blocks after cesarean delivery in people with OUD.
DISCUSSION
Although peer-reviewed publications on peripartum pain management in patients with OUD have steadily increased over the years, most of these publications are low on the hierarchy of evidence, with very few randomized trials and systematic reviews compared to available evidence on pain management in other obstetric populations. Published articles do not specify each of the 4 populations of OUD and MOUD that we specified, indicating a potential need to focus future work on these conditions. Future studies should focus on 3 key areas. First, it is important to identify heterogeneity of clinical symptoms or treatment effects among pregnant people with OUD. Next, it is critical to assess the effect of OUD or MOUD on acute pain conditions. Finally, studies should identify the influence or interaction of postpartum labor pain and the birth experience on recovery outcomes for people with OUD.
In this review, the consensus questions were considered for specific populations, namely: (1) pregnant people with MOUD for whom OUD was due to pain condition; (2) pregnant people receiving MOUD for whom OUD was not due to pain condition; (3) pregnant people with untreated OUD; and (4) pregnant people with OUD who were stable in recovery after not receiving MOUD. These groups are critical to study, and it is important to come to a consensus on best practices for their management in acute care settings such as labor and delivery.
Although not a part of this review, most peripartum pain management trials have actively excluded people with OUD. Future research should focus on this special population. Alternatively, studies should include them in sampling, with appropriate analyses and sample size calculations that aim to detect differences in this subpopulation of interest.
The following themes in knowledge gaps and research opportunities were recognized in this review.
Opioid Use for Pain Management in Labor and Delivery
The phenomenon of opioid-induced hyperalgesia and opioid tolerance has shaped some published opinions that high doses of opioids will be needed for peripartum pain management in patients on opioid agonist therapies. However, exposure to parenteral opioids can also increase risk for return to opioid use. Simultaneously, poor pain control can also increase risk for return to opioid use. The available evidence highlights the need for rigorous research that will identify specific patients who may benefit from, and who may be harmed by, opioid use for peripartum pain management. Other improvements for scientific rigor include standardizing pain assessments and characterizing return to use. High-quality evidence will better guide clinicians on optimal ways to prescribe and monitor opioid use after discharge in patients with OUD.
Management of Comorbid Pain and Psychological Conditions
The available literature shows that psychological comorbidities are common among pregnant people with OUD. These comorbidities include anxiety, depression, trauma history, and polysubstance use history. However, there is a lack of high-quality studies on ideal methods to optimize psychological and psychosocial comorbidities around delivery. Although social support strategies are essential components of multimodal pain management in nonobstetric settings, the literature related to this current review is focused on these interventions for addiction management. Effectiveness studies on social support interventions for postpartum pain management are lacking.
Notably, no publications discussed naloxone coprescribing for addiction management, neither in the labor and delivery setting, nor as it relates to opioid prescribing for pain management. Naloxone is an important part of the public health response to the opioid crisis. Given that overdoses are one of the leading causes of maternal death in the United States, naloxone coprescribing in pregnant and recently pregnant people, although essential, does not appear to be current standard medical management.
Optimal Neuraxial Analgesia Dosing Strategies, Adjuncts, and Supplemental Abdominal Wall Blocks
Case reports, series, and retrospective reviews describe the use of neuraxial analgesia for labor and delivery and postpartum pain management, with many5,19,20,29,34,39,49,56,67–71 noting no evidence for increased medication (local anesthetic) use during labor analgesia. The harms of maintaining postpartum neuraxial analgesia are not mentioned in the literature, including potential for increasing risk for thromboembolic events as well as limiting early ambulation goals outlined by published Enhanced Recovery after Cesarean Delivery (ERAC) guidelines.88 Future research is needed on best local anesthetic dosing strategies, and on neuraxial adjuncts and their doses (eg, clonidine, dexmedetomidine, lipophilic opioids, and others). For cesarean deliveries, there were no trials specifically addressing the potential role that supplemental abdominal wall blocks (such as CWI, TAP, or QL blocks) may have for optimizing pain management among people with OUD.
Monitoring and Alternative (Nonopioid and Nonpharmacologic) Methods of Analgesia
The risk for respiratory depression and moderate sedation when systemic opioids are used for in-hospital peripartum pain management in patients with OUD has been reported.88 There is an opportunity to focus research on monitoring and safety outcomes in these settings. Ketamine, N2O, and other alternative analgesia methods require further study for effectiveness and potential harms in this special population. The data are limited, but the safety concerns also highlight the need for research on alternative, nonopioid, and potentially nonpharmacologic analgesic strategies in this special population.
CONCLUSIONS
Since 1975, more than 80 publications on peripartum pain management in people with OUD have been primarily of low quality, including case reports, cohort studies, and narrative review articles. Moving forward, studies and publications in this area should focus on generating high-quality evidence to guide clinical practice based on research with rigorous methodologies. Pregnant people with OUD should not be excluded from peripartum pain research; instead, studies should be adequately powered to examine subgroup analyses or should exclusively focus on this special population. Systematic and narrative review articles and expert opinions may need to be deemphasized until more (and higher-quality) evidence becomes available.
Leave a Reply
You must be logged in to post a comment.