Labor and Pain Management Strategies for Patients with Opioid Use Disorder

Dr. Flood started her career with Columbia University, was the Director of Obstetrical Anesthesiology at the University of California, San Francisco, then moved to Stanford, which has one of the preeminent clinical and research pain divisions in the country. Dr. Flood’s recent research and clinical work has been focused on clinical and translational aspects of pain, including labor and post-delivery pain. She highlighted some key points that must be understood regarding women diagnosed with OUD.

First, in general, when a woman is taking high-dose opioids, the nerves are sensitized, so even a stimulus that might seem slight, like using a tourniquet, can be much more painful to them because the physiology of their nerves has changed. The small stimulus activates the nerve in a way that would require a much larger stimulus in someone without exposure to high-dose opioids. Dr. Flood expressed how this is a common misunderstanding and causes people to treat patients with OUD unkindly when something that might seem small is very painful, despite their high-dose baseline opioids.

Second, when a woman being treated with opioid replacement therapy presents, it is critical that the treatment be continued throughout the birthing process. Opioid agonists such as methadone or buprenorphine work effectively to prevent withdrawal symptoms and relieve drug cravings by acting on opioid receptors in the brain. The patient does not get high or euphoric, and it does not provide pain relief. During labor, the epidural acts to control birth pain but it doesn’t prevent withdrawal. It’s a misconception that these patients are on replacement therapy for pain relief. If their withdrawal medications are stopped, they experience the horrible physiological changes of withdrawal during the physiological stress of delivery.

Another common misinterpretation is that there is a benefit to stopping the medication to the fetus. The fetus has been exposed throughout their development and, depending on the drug and its dose, the baby may not go through withdrawal. Sometimes the fetus will have to be treated by a perinatologist and slowly helped through withdrawal, but it’s safer than the alternative of unsupervised withdrawal from street drugs.

Finally, it should also be noted that doctors are able to use some of the same birthing protocols for women who aren’t taking opioids versus those with OUD. An epidural using local anesthetic, for example, can be administered because there is no cross-tolerance with replacement therapy drugs and local anesthetics. Another acceptable birthing protocol involves using local anesthetics in the ON-Q catheter, which is threaded between abdominal muscles after cesarean delivery. “The key to medicine in general,” Dr. Flood explained, “is taking advantage of synergy.” Every medication has a dose response curve, with effects and side effects, so the objective is to use an effective dose, or combination of medications, with minimal side effects.

Throughout her research, Dr. Flood realized that a protocol should be put in place for every parturient patient (in treatment or not), as most institutions care for women with opioid use disorder. To avoid a haphazard situation with obstetric anesthesiologists using medicines they aren’t familiar with, along with pain medicine practitioners stepping into an unknown world, the need for a protocol arose.

This Multimodal Pain Management Pathway was developed at Stanford by Dr. Flood, along with other OB anesthesiologists and pain practitioners, for treating a woman with opioid use disorder undergoing cesarean delivery, starting from obstetrics to pediatrics. It details how to manage their pain, given women with opioid use disorder can arrive in various states of treatment. Untreated parturients are at highest risk for other variables. These patients could be on other drugs, withdrawing from the drug, malnourished, and have other psychosocial stresses. Without replacement treatment such as methadone or buprenorphine, they are at high risk for abrupt withdrawal.

The best possible scenario is caring for a woman in treatment, due to strong evidence for replacement treatment and opportunity for follow-up. The protocol outlines considerations regarding care during the preoperative, intraoperative, and postoperative phases of a cesarean delivery.

It is of critical importance to have the patient reviewed in a multidisciplinary manner whenever possible.

• The patient should be referred for an OB anesthesia consult.
• A multimodal analgesic plan should be developed with established expectations for the patient and providers.
• Patient concerns, fears, and prior experiences should be addressed and acknowledged.
• The patient’s maintenance buprenorphine or methadone dose must be continued throughout the prepartum period without change, unless instructed by pain or addiction management professionals.

During the preoperative stage, the team details special recommendations for patients with OUD who are not in treatment. Recommendations may include different avenues for those with a remote history of using who may not want exposure to opioids and those actively using.

During surgery, the protocol lists specific dosages of medicine to be administered, procedures for patients on buprenorphine or methadone (along with no treatment) for either a spinal or epidural anesthetic, and directives for using an ON-Q catheter or TAP (transabdominal plane block) alternative.

Finally, for the postoperative stage, Dr. Flood and her team highlight considerations such as postpartum obstetric anesthesia evaluations and more medication recommendations for opioids and nonopioid adjuvants. The pathway concludes with important notes such as advising for acute pain service consults, psychiatry or addiction medicine follow-ups, and discharge advice concerning analgesia communication to the OB and outpatient care team.

In summary, there are essential insights to be learned from the Multimodal Pain Management Pathway:

1. If the patient is on opioid maintenance, it must be upheld. Along these lines, recognize the fact that patients with OUD have unique nervous systems and experiences with medical care.
2. Regional anesthesia can be used in the conventional way and should be taken advantage of when possible.
3. Adjuvant medicines will often be needed in addition to opioids. If unfamiliar, confer with pain or addiction medicine colleagues, or others.
4. It is a smart idea to have an institutional protocol in place. Collaborate on a pathway with those who are knowledgeable on the topic and ensure it is certified.

Kim Sumrak is a freelance writer and magazine content manager.