Opioid-use disorder (OUD) in pregnancy increased significantly in the past decade1 and is a leading cause of maternal morbidity and mortality in the United States,2 primarily due to opioid overdose and co-occurring mental health conditions. Notably for readers of Anesthesia & Analgesia, the quality of intrapartum and postpartum pain management may influence long-term outcomes for these patients, particularly rates of peripartum depression and a return to illicit substance use.3 Effective pain management during the postpartum period can bolster trust in the health care system and promote continuous engagement with clinicians throughout the vulnerable “fourth trimester” or postpartum period. Conversely, breaches of trust stemming from inadequate pain management and perceived biases may lead to disengagement, loss to follow-up, and an increased risk of relapse, ultimately heightening the risk of overdose and mortality in this vulnerable population.
Barriers to high-quality care abound. Clinicians may be hesitant to adequately address pain due to biases regarding patients’ reported pain, insufficient education, and a lack of comfort in managing complex pain.4 A lack of clear guidelines for treating pain in this population has often led to under-treatment, primarily due to fears of overprescribing pain medications, especially in conjunction with ongoing treatment for OUD or active illicit substance use.4 Moreover, pregnant people with OUD often experience stigma and harbor fears about engaging with health care systems,4 particularly due to potential involvement from Child Protective Services.5 This mistrust is compounded by significant social and structural barriers such as limited transportation and housing insecurity often contributing to late initiation of prenatal care and limiting opportunities for antepartum anticipatory guidance regarding delivery and peripartum pain management.
THE NEW CONSENSUS STATEMENT
To address the complexities of pain management in peripartum patients with OUD, authors from obstetric anesthesiology, pain medicine, obstetrics, maternal-fetal medicine, and addiction medicine convened to create a new multi-society consensus statement, published in the current edition of the journal.6 The consensus statement provides recommendations for almost 40 distinct clinical questions related to OUD in pregnancy, spanning antepartum, intrapartum, and postpartum care. Drawing on evidence from a 2022 systematic review of peri-delivery pain management for patients with OUD,7 which consisted of 84 publications, the writing group applied the American College of Cardiology and American Heart Association Clinical Practice Guideline Recommendation Classification Systems to evaluate the level of evidence for each question and develop clinical recommendations for health care providers.7,8 Each topic is broken down into a clinical question, summary of the published literature, and ultimately a clinical recommendation based on the available evidence and/or expert opinion.
Unfortunately, the evidence on pain management for pregnant and postpartum women with OUD is scant. Much of the evidence is indirect, derived from pregnant people without OUD or from nonpregnant people with OUD. Given this paucity of evidence, the consensus statement includes only one Class 1 (Strong) recommendation based on Level A evidence: “NSAIDS and acetaminophen should be administered on a set schedule post vaginal delivery with OUD.” Remarkably, no randomized trial is cited to support this recommendation. A similar Class 1 (Strong) recommendation is made for scheduled nonsteroidal anti-inflammatory drugs (NSAIDs) with acetaminophen after cesarean delivery, but here, the quality of evidence is rated as Level B-R, indicating “moderate-quality evidence.” The majority of recommendations in the consensus statement rely on expert opinion. Fortunately, the writing group included a group of experts with extensive experience in the clinical management of pregnant people with OUD, and they address a range of issues that are highly relevant to clinical practice.
Key topics include optimal medication management for OUD as well as labor and cesarean delivery pain management recommendations. Both methadone and buprenorphine are recommended medications for the treatment of OUD in pregnancy, given an increased risk of relapse and worse outcomes when compared with medically supervised withdrawal, and should be continued peri-delivery.9,10 Current recommendations for labor analgesia and cesarean delivery generally defer to evidence-based practices for non-OUD pregnant patients, with consideration to an early labor epidural, initial utilization of a dilute solution of local anesthetic for analgesic maintenance, scheduled multimodal analgesics, and hydrophilic neuraxial opioid administration as part of multimodal analgesia after cesarean delivery.
At the same time, the authors highlight increases in pain sensitivity, and review a number of interventions with insufficient evidence to support standardized use in pregnant patients without OUD. In the event of cesarean delivery, abdominal wall blocks or 12 to 24 hours of epidural analgesia are recommended. Additional nonopioid analgesics and neuraxial adjuncts are also discussed at length in the recommendations.
While this consensus statement seeks to increase standardization of care for OUD in pregnancy with existing evidence and expert opinion, it also emphasizes the need for individualization as a central tenet. As an example, many patients with OUD may choose to avoid all narcotics during the postpartum period due to fears of triggering cravings, while others may view the use of short courses of narcotics as essential to managing their postoperative pain. A patient-centered approach focuses on the patient’s pain management goals, including preferred medications and alternatives, along with clear documentation of substances they wish to avoid. This mirrors the approach to pain management preferences in the general obstetric population, where individual plans can vary significantly.
Included are also a number of safety considerations for providers caring for patients with OUD in pregnancy. For example, in pregnant people on medications for OUD (MOUD), clinicians should avoid treating neuraxial-induced pruritis with partial opioid antagonists, such as nalbuphine, given concerns about inducing acute withdrawal. In postpartum patients who have received hydrophilic neuraxial opioids, ventilatory monitoring for delayed respiratory depression should be stratified to the “high-risk category” with 24 hours of ventilatory checks.11 Finally, in the event of buprenorphine-induced respiratory depression, treatment may require dramatically increased doses of opioid antagonists (Narcan) (some requiring >2 mg).
KEY CONSIDERATIONS FOR ADDRESSING RESEARCH GAPS FOR PAIN MANAGEMENT IN PERIPARTUM OUD
Research on the intersection of pain and OUD in pregnancy remains a developing field with several key questions that merit attention. The consensus statement points to the need for research that bridges the intrapartum and postpartum periods, and answers questions about how peripartum analgesia impacts long-term outcomes for women with OUD, including engagement in treatment for mental health and OUDs.
A number of considerations impact the ability to close research gaps on pain and OUD in pregnancy. While public recognition of the opioid crisis has increased in recent years, with historically high rates of overdose deaths, the prevalence of OUD in pregnancy is sufficiently low that even the busiest delivery units cannot pursue meaningful single-center clinical research on this topic. It follows that rigorous research for pain and OUD in pregnancy will require evidence drawn from clinical care delivered at multiple centers and sites.
Various research designs offer the potential to move the field forward for pain care in OUD and pregnancy. While multisite clinical trials stand at the apex of the evidence pyramid, time, money, and other barriers lessen their feasibility. Nonrandomized observational designs that rely on data sources such as patient registries and insurance claims have the potential to advance the evidence base beyond indirect evidence and expert opinion. Both sources offer the opportunity to capture and analyze larger samples of patients, and in doing so permit more advanced analytical methods such as target trial emulation.12 Further research opportunities may result from the linkage of data between registry and claims sources, such as analyzing intraoperative data from the Multisite Perioperative Outcomes Group connected to a large patient safety registry or national health insurance claims database. In doing so, opportunities arise to focus on outcomes spanning labor and intrapartum pain care through well after return home where outcomes that center on patient well-being matter, not the least of which is retention in therapy for those taking medications for MOUD. Of course, observational data carries limitations. Billing codes, pharmaceutical claims, or diagnoses listed in the electronic health records may misclassify patients with OUD,13 and none can match the accuracy of a prospectively collected clinical assessment of the twelve DSM-5 criteria for OUD by an addiction medicine specialist.
ADDRESSING CHALLENGES IN MANAGING PAIN IN PATIENTS WITH PERIPARTUM OUD
As we recognize the limitations of current research designs in effectively addressing pain management for peripartum patients with OUD, it becomes essential to focus on workforce development strategies that target the existing gaps in care, ensuring that health care providers are equipped with necessary skills and knowledge to effectively support this vulnerable population.
Despite efforts by professional medical societies, governmental agencies, and changes to federal legislation relaxing restrictions for access to MOUD, many parts of the country still lack accessible addiction medicine care, particularly in rural areas, and particularly for pregnant and postpartum women.14 Areas with a geographic overlap between high-risk obstetric populations and absent clinical resources have been described as “maternal mental health dark zones.” Community-based programs are emerging to help to bridge the gaps in care with both clinical and nonclinical resources (eg, the Veteran’s Administration National Maternity Care Coordination Program); however, efforts to facilitate communication and linkages between medical providers and community-based efforts remain fragmented.
Many providers are ill-equipped to treat substance-use disorders (SUDs) due to a lack of formal training. Conversely, Specialists in addiction medicine, who provide evidence-based approaches and expertise to handle complex care, are increasingly sought by health systems, academic institutions, hospitals, medical groups, and public health organizations. National efforts to expand the addiction medicine workforce, including those by Substance Abuse and Mental Health Services Administration (SAMHSA), Health Resources and Services Administration (HRSA), and The Opioid Workforce Act of 2021, have supported the creation and expansion of more than 1000 newly funded training opportunities. The American College of Academic Addiction Medicine partnered with the American Colleges of Graduate Medical Education (ACGME) to establish a system to accredit addiction medicine fellowships, which are 12 months in duration, admit physicians from any of the 24 primary medical specialties, and provide experience in a range of settings from general care, public health, and specialty settings. Additionally, for those with established clinical expertise in addiction medicine, there are multiple board certification pathways that do not require additional fellowship training.15
Efforts to overcome workforce shortages and provide more comprehensive and holistic care may include integrative health care models where either consultation or colocated services can occur. This can be through projects like Mobile Health Care units, Collaborative Care Models, telehealth, or Integrative Behavioral Health models. Multiple large telemedicine-based Maternal Fetal Medicine (MFM) programs have been developed to address the lack of MFM availability in rural settings. Through this work, multiple hybrid prenatal/perinatal care programs have proven efficient in providing self-monitoring tools, embracing text messaging platforms, and facilitating telehealth appointments to access specialty care. Many specific aspects of MFM care have also been readily adapted to telehealth platforms, such as diabetes management, remote blood pressure monitoring, and smoking cessation, and could be supplemented with screenings and mental health/SUD care. Additionally, those women suffering from MH/SUDs could be connected with online addiction recovery support meetings and peer support services. Telehealth care could also be expanded to facilitate improved access to antepartum and postpartum care for patients in remote locations without available specialists and subspecialists, including anesthesia for delivery planning. Providing integrative, psychological, and low-barrier access to care is advocated and supported by anesthesia organizations, American College of Obstetricians and Gynecologists (ACOG) and the World Health Organization. Ultimately, improved maternal outcomes involving mental health and SUDs in pregnant women will require substantial integrated strategies and care that cross medical, community, and social systems. By enhancing training and resources, we can improve outcomes for peripartum patients with OUD and ultimately bridge the divide in care delivery.
CONCLUSIONS
Pain management in a patient with OUD presents a host of challenges for the health care provider, challenges that often become even more complex in pregnancy. These multi-society recommendations serve as a roadmap for caring for pregnant persons with OUD. In many ways, this consensus statement also serves as a “call to action,” emphasizing the need for multi-disciplinary collaboration, further research, workforce development, and improved access to care to optimize outcomes for patients with OUD in pregnancy.
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