National data indicate that the majority of maternal deaths associated with OUD occur during pregnancy or within 6 weeks postpartum.3 In addition to being at risk for mortality caused by opioid overdose, parturients with OUD also have significantly increased odds of death during their delivery hospitalization and of experiencing cardiac and cerebrovascular events.4 The intersection of the ongoing opioid epidemic and the current COVID-19 pandemic is of particular concern. Although pregnancy-specific numbers are not yet available, provisional data on drug overdose deaths among the general US population reveal a 21% increase in 2020, compared with the previous year.5
When untreated, OUD is also associated with morbidity for infants, including intrauterine growth restriction and preterm birth.4,6 Chronic in-utero withdrawal from opioids is also linked to poor fetal outcomes.7 After birth, NOWS may result in expensive and lengthy hospitalizations for infants. Active substance use during pregnancy or parenting is a frequent reason for child protective service involvement.8-10 Fortunately, treatment of OUD improves perinatal outcomes, decreases NOWS severity and length of infant hospitalization, and prevents opioid-related maternal mortality.11-17
Population-based research shows that timely access to medication for opioid use disorders (MOUD) significantly reduces rates of overdose during pregnancy and the first postpartum year.14 However, despite the well-documented benefits of MOUD, many pregnant patients do not receive evidence-based treatment.14 Lack of providers willing to prescribe MOUD during pregnancy, economic challenges, transportation problems, untreated mental health conditions, and competing family responsibilities contribute to poor engagement in treatment during pregnancy and postpartum.18-22
Nationally, access to MOUD lags well behind demand, especially in rural areas and for Medicaid-insured patients.23-26 Ob/gyn providers frequently serve as the primary contact with the health care system for pregnant and postpartum people and can therefore play an important role in meeting critical gaps in treatment access.27-29 The goal of this article is to provide tools and strategies for practicing ob/gyn physicians seeking to improve outcomes for patients with OUD.
Role of obstetric providers
Pregnancy is a critically important time for self-care. However, while pregnant patients are typically motivated to engage in substance use treatment,30 they benefit from being met halfway by knowledgeable and supportive providers. All members of the obstetric team should understand not only the perinatal risks associated with exposure to commonly used substances, but also strategies to mitigate them, including treatment options for OUD.
During pregnancy, obstetric providers routinely screen for chronic conditions that impact perinatal health and manage these either independently or in collaboration with other specialties. As with other chronic conditions, management of OUD during pregnancy is best accomplished by a multidisciplinary team, including nursing and/or social work for care management and behavioral health when available. Similarly, specialists in addiction medicine should be consulted and may need to assume management in the case of severe or complicated disease.
Acknowledging the rising prevalence and negative outcomes associated with perinatal OUD, the American College of Obstetricians and Gynecologists (ACOG), the Society for Maternal-Fetal Medicine (SMFM), and the American Society of Addiction Medicine (ASAM) have joined forces to encourage ob/gyn physicians to take an active role in screening, diagnosis, and treatment of OUD among pregnant patients.31-33
Screening for perinatal substance use
Developed by the Substance Use and Mental Health Services Administration (SAMHSA), the screening, brief intervention, and referral to treatment (SBIRT) framework34 is a useful way to conceptualize risk identification and linkage to care for OUD. This framework, which includes verbal screening for substance use, can be readily incorporated into routine perinatal assessment during prenatal and postpartum care.35 The vast majority of pregnant patients will disclose little or mild risk for prenatal substance use and require only education and brief advice regarding the benefits of abstinence. However, for a smaller proportion, identifying an untreated substance use disorder, and linking a pregnant patient to appropriate treatment, can be lifesaving.
Both ACOG and SMFM recommend universal verbal screening for drug and alcohol use starting at the initial prenatal visit. The 2019 SMFM Special Report on Substance Use Disorders in Pregnancy recommends a number of validated instruments; of these, the NIDA screen is available in both written and digital formats.36 Experts at SAMHSA37 as well as SMFM, ACOG, and ASAM31 concur in advising against biologic testing (eg, urine drug tests) as a method of general screening for substance use, recommending that toxicology testing be used only in specific clinical scenarios.
Validated screening instruments are useful in identifying risky substance use but are not diagnostic of a substance use disorder.31 Any positive screening should be followed by a nonjudgmental conversation to determine the type of substance or substances involved, potential for physiologic dependence, and treatment needs.35 This discussion must be informed by the recognition that OUD and other substance use disorders are chronic medical conditions rather than behavioral choice. Scripting and guidance for conducting a standardized brief intervention is available for providers.36-39 Because many pregnant patients with OUD experience significant anxiety and guilt about its potential impact on the fetus and newborn, they may experience relief when encountering a knowledgeable and caring provider.30 Of note, while these conversations take time, physicians may bill for either time spent in counseling or medical decision-making to address perinatal substance use40 and associated social determinants of health,41 in addition to routine maternity care.
Referral for treatment
The standard of care for treating OUD during pregnancy is MOUD with either methadone or buprenorphine.31-33,37 Choice of medication should be determined through a shared decision-making process, informed by the patient’s preferences and internal and external resources, as well as the availability of treatment options in the community.37,42-43 Methadone, which has been the mainstay of treatment for OUD since the 1970s, is a long-acting opioid agonist medication that activates the brain’s opioid receptors, resolving and preventing cravings for opioids. A full mu agonist, methadone has typical opioid side effects, including somnolence and respiratory depression, and must be titrated slowly following strict protocols. By federal law, treatment with methadone may be provided only through licensed opioid treatment programs (OTPs), typically with daily observed dosing. Although the structured schedule imposed by OTPs can be challenging for patients living in remote rural areas or who have transportation barriers, it can also be helpful for those who have difficulty safely storing or managing their own medications.
Buprenorphine, a partial agonist introduced more recently for the treatment of OUD, also binds strongly to opioid receptors, but with partial activation resulting in reduced adverse effects and a more favorable safety profile. Unlike methadone, buprenorphine can be prescribed by qualified providers in general medical settings after they complete targeted training and obtain a waiver from the US Drug Enforcement Agency (DEA).44 Buprenorphine is typically administered sublingually either as buprenorphine monoproduct or a combined buprenorphine-naloxone formulation.
Although initially only the buprenorphine monoproduct was recommended for prenatal use, a growing body of research has demonstrated that the two formulations are equally safe and effective during pregnancy and lactation.45 Due to the unique pharmacology of buprenorphine, initiation of this medication should be attempted only when a patient is in active withdrawal, after which titration to a therapeutic dose can be accomplished over several days. Buprenorphine is self-administered and generally refilled weekly to monthly. Although long-acting injectable formulations of buprenorphine are available, these are not recommended for use during pregnancy or lactation.
Some pregnant patients with OUD will ask about the safety of detoxification. Medically assisted withdrawal (MAW) is not recommended due to high rates of relapse and attrition associated with this approach.46 However, it is not contraindicated if carefully managed.37 Patients cite a number of factors leading to choosing MAW, including the desire to avoid NOWS for their infants, fear of child protection, and fear of stigma associated with being pregnant and receiving MOUD, including from family members.47 It is critically important that patients attempting MAW have access to behavioral health care to support continued recovery and are given the opportunity to change course and transition to MOUD as needed. Regardless of treatment choice, all patients with OUD should be offered a prescription for the lifesaving opioid reversal drug naloxone along with appropriate education about how to identify an opioid overdose and administer naloxone.32
Clinical guidance for the perinatal care of patients with OUD
In 2018, recognizing the complexity of perinatal opioid use disorder, the common medical and psychiatric comorbidities described previously, and treatment options, SAMHSA published “Clinical Guidance for Treating Pregnant and Postpartum Women with Opioid Use Disorder and Their Infants.”37 The guidance document was developed “to meet an urgent need among professionals who care for women with OUD…for reliable, useful, and accurate information that can be applied in clinical practice to optimize the outcome for both mother and infant.”37 To support the implementation of best practice and improve quality and outcomes, the Alliance for Innovation on Maternal Health (AIM) subsequently published a patient safety bundle for the care of obstetric patients with OUD.48 The bundle provides a clinical pathway for the comprehensive care of patients with OUD during pregnancy, including screening and management of comorbid mental health conditions, HIV, and hepatitis B and C, and guidance regarding drug testing, peripartum pain management, care for infants experiencing NOWS, breastfeeding, and addressing stigma among staff. These resources are web-based and include a wealth of information to support maternity care teams in optimizing care. Continuing medical education based on the AIM patient safety bundle is available as an e-module through ACOG.49
The postpartum period is a time of extreme vulnerability for patients with OUD, when exhaustion, the added responsibility of caring for a baby, and mental health symptoms can challenge recovery. At the same time, losing contact with trusted maternity care providers and potential termination of insurance increase the risk of treatment discontinuation, relapse, and potentially fatal overdose.50-53
For patients with OUD, the recently published ACOG Committee Opinion on optimizing postpartum care, which extends the traditional window of postpartum engagement to 12 weeks or more,54 is particularly relevant. Continuity of care during this period is essential to facilitate screening and treatment for postpartum depression, allow shared decision-making about contraception, promote long-term breastfeeding, and ensure a warm handoff to primary care and ongoing substance use treatment.
Acute Opioid Withdrawal During Pregnancy
Obstetricians may find themselves in the position of assessing a pregnant patient who presents in acute opioid withdrawal. In many contexts, there may be no one else able to initiate urgent treatment, especially in rural areas or community hospitals without psychiatric services.29
Both ACOG and SMFM endorse the initiation of buprenorphine for patients with untreated OUD as part of general obstetric practice.31 In the inpatient setting, any prescribing provider may initiate medication to treat acute opioid withdrawal complicating pregnancy, allowing time for referral to community-based treatment providers for ongoing management. In addition to addressing an immediate need with significant implications for maternal and fetal health, this approach promotes close collaboration between maternity and addiction treatment providers.
Buprenorphine prescribing has been tightly controlled by the DEA since its approval for the treatment of OUD in 2002. Physicians, advanced practice nurses, and physician assistants may prescribe buprenorphine after completing required training on the diagnosis and treatment of opioid use disorder and applying for a waiver from DEA to prescribe buprenorphine.
In part because of these regulatory barriers, the proportion of obstetric providers who obtain a waiver is small, including only 1.8% of ob/gyn physicians who care for Medicaid claimants nationally.28 The relatively small number of waivered providers has led to calls to lift the waiver requirement, but it is unknown whether policy changes will be forthcoming.
Perinatal OUD is increasingly a driver of pregnancy associated morbidity and mortality in the United States. Obstetric providers, accustomed to the management of pregnancies with medical risks, are uniquely positioned to promote healthy pregnancy for patients living with OUD/ SUD. Given the high rates of perinatal substance exposure nationally, and its negative impact on maternal, fetal, and neonatal health, our professional societies call on us to actively engage in improving care and outcomes for this vulnerable population.
Although the medical management of opioid use disorder is outside the scope of training of most obstetric providers, expert guidance is available from ACOG, SMFM, SAMHSA, and AIM for the delivery of effective patient-centered services to patients with OUD. A multidisciplinary, team-based approach allows each member to focus on their own area of expertise while facilitating communication and optimizing care.
Members of maternity care teams should have a working knowledge of the perinatal risks, common comorbidities, and treatment options for OUD. Additionally, both ACOG and SMFM encourage obstetricians to incorporate buprenorphine prescribing into their practice to facilitate timely access to treatment and reduce morbidity and mortality during pregnancy and postpartum.