The Psychiatrist’s Role in Treating Perinatal Opioid Use Disorder and Reducing Maternal Mortality
Abstract
Drug overdose is a leading cause of maternal mortality. Psychiatrists can play a critical role in reducing these deaths by delivering effective evidence-based treatments for perinatal opioid use disorder (POUD), including the use of buprenorphine. Medications for POUD (i.e., buprenorphine, methadone) are life-saving treatments, but only half of those who are diagnosed as having POUD will receive this treatment, which can result in an increased risk for return to opioid use, overdose, and death. Psychiatrists are well positioned to prescribe buprenorphine given the Drug Enforcement Administration’s (DEA) removal of the requirement to submit a Notice of Intent to prescribe buprenorphine for the treatment of opioid use disorders. Psychiatrists who have a current DEA registration that includes Schedule III authority may now prescribe buprenorphine for opioid use disorders; the training requirements to do so are outlined herein. This article reviews the standard of care for screening, diagnosis, and treatment of POUD, and prescribing buprenorphine for POUD, as well as shared decision-making for medication selection, induction, and maintenance of buprenorphine during pregnancy, labor and delivery, and the postpartum year.
In the United States, maternal mortality (i.e., death during pregnancy or the year postpartum) is higher than every other developed country (1). The most recent data from the Centers for Disease Control and Prevention (CDC), including 1,018 pregnancy-related deaths from 36 U.S. states between 2017 and 2019, demonstrate that mental health conditions accounted for 22.7% of all maternal deaths—a percentage that is higher than any other cause of mortality (2). Similarly, a review of 11,782 pregnancy-related deaths from 33 U.S. states and D.C. during 2010 to 2019 demonstrates that suicide, drug overdose, and homicide accounted for 22.2% of deaths (3). Over this 9-year period, maternal drug-related deaths increased by 190%, suicide by 30%, and homicide by 63% (3).
Between 2017 and 2020, pregnancy-associated overdose mortality increased from 6.56 to 11.85 per 100,000 live births: a relative increase of 81% (4). Most pregnancy-associated deaths involve benzodiazepines, heroin, and prescription opioids, with the largest increase in recent deaths involving a combination of high-potency synthetic opioids, primarily illicitly manufactured fentanyl and fentanyl analogs, and psychostimulants (e.g., methamphetamine, cocaine). Increases in deaths due to fentanyl and other high-potency synthetic opioids were especially marked in 2020, increasing from 5.73 per 100,000 in 2017 to 9.47 per 100,000 in 2020. Alarmingly, the U.S. drug supply is becoming increasingly contaminated by drugs that are adulterated with varying amounts of fentanyl—which is up to 50 times more potent than heroin and 100 times more potent than morphine. This further contributes to the unprecedented rates of overdose (5–7). With regard to maternal mortality, deaths from overdose most commonly occur during the late postpartum period, compared with pregnancy or early postpartum (4). Many of these deaths are attributable to undetected and untreated opioid use disorder.
Opioid use disorder affects approximately 23,400 pregnant women annually (8). In the last 20 years, opioid use disorder among pregnant women has increased 333%, from 1.5 to 6.5 cases per 1,000 deliveries (9). Neonatal opioid withdrawal syndrome (NOWS) has increased from 1.2 to 8.8 per 1,000 hospital births (10). Prenatal opioid use is associated with deleterious maternal and fetal and child outcomes, including stillbirth and pregnancy-associated death (10, 11). Yet, recent data from CDC indicate 84.2% of maternal deaths are preventable, and Maternal Morbidity and Mortality Review Committees from 14 states report that 100% of maternal mental health–related deaths, including drug-related overdose, are preventable (12, 13). As such, increasing access to evidence-based interventions for perinatal opioid use disorder (POUD) represents a key strategy for preventing opioid-related deaths among pregnant and birthing people.
Psychiatrists can play a critical role in reducing pregnancy-associated mental health deaths by delivering effective evidence-based treatments for POUD. Per several professional organizations, the standard of care for the treatment of POUD includes pharmacotherapy with either methadone or buprenorphine combined with other pharmacological and psychological interventions for relapse prevention and/or the treatment of comorbid mental health conditions (14, 15). Medications for opioid use disorder (MOUD), i.e., buprenorphine or methadone, are the first-line treatment for pregnant and/or lactating women and offer significant protection against overdose (16). A longer duration of MOUD use in pregnancy is associated with increasing protection against overdose, with a 57% reduced risk after 10 weeks of MOUD use in pregnancy and up to 97% reduced risk when MOUD is used continuously throughout pregnancy (17). Despite the efficacy of MOUD, utilization and retention are poor (18–20). Of peripartum people who do receive MOUD, up to 56% have poor retention and discontinue treatment early (21). Psychiatrists are well positioned to deliver this treatment, especially now given the removal of the federal requirement for practitioners to submit a Notice of Intent (have a waiver) to prescribe buprenorphine for the treatment of opioid use disorder (Consolidated Appropriations Act, 2023, also known as the Omnibus bill). All practitioners who have a current Drug Enforcement Administration (DEA) registration that includes Schedule III authority may now prescribe buprenorphine for opioid use disorder. Effective June 27, 2023, the Medication Access and Training Expansion (MATE) Act requires that practitioners who are applying for or renewing their DEA registration to prescribe controlled substances must complete a one-time 8-hour training on the treatment and management of opioid and other substance use disorders. Individuals who are board certified in addiction medicine or addiction psychiatry; have graduated within 5 years in good standing from medical, advanced practice nursing, or physician assistant school in the United States that included completing of opioid or other substance use disorder curriculum; or completed the previous 8-hour training requirements to prescribe buprenorphine (i.e., X-waivered) are considered to have satisfied this training requirement. For more information, see https://www.samhsa.gov/medications-substance-use-disorders/training-requirements-mate-act-resources.
The goal of this review is to support psychiatric providers in delivering evidence-based care for pregnant and postpartum people diagnosed as having opioid use disorder. We provide guidance on screening, diagnosis, and treatment as well as how to access additional and ongoing support and education in treating POUDs.
Assessment, Diagnosis, and Monitoring of Opioid Use Disorder
According to the DSM-5, opioid use disorder is a chronic, relapsing disorder that is characterized by a problematic pattern of opioid use leading to clinically significant impairment, problems, or distress (22). See Box 1 for DSM-5 diagnostic criteria for opioid use disorder.
BOX 1. DSM-5 criteria for opioid use disordera
A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
1.
Opioids are often taken in larger amounts or over a longer period than was intended.
2.
There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
3.
A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
4.
Craving, or a strong desire or urge to use opioids.
5.
Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.
6.
Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
7.
Important social, occupational, or recreational activities are given up or reduced because of opioid use.
8.
Recurrent opioid use in situations in which it is physically hazardous.
9.
Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
10.
Tolerance, as defined by either of the following:
a.
A need for markedly increased amounts of opioids to achieve intoxication or desired effect.
b.
A markedly diminished effect with continued use of the same amount of an opioid.
Note: This criterion is not considered to be met for those taking opioids solely under appropriate medical supervision.
11.
Withdrawal, as manifested by either of the following:
a.
The characteristic opioid withdrawal syndrome (refer to Criteria A and B of the criteria set for opioid withdrawal).
b.
Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms.
Note: This criterion is not considered to be met for those individuals taking opioids solely under appropriate medical supervision.
Specify Current Severity
•
Mild: Presence of 2–3 symptoms.
•
Moderate: Presence of 4–5 symptoms.
•
Severe: Presence of 6 or more symptoms.
__________________________
a Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC, American Psychiatric Association, 2013. Copyright © 2013 American Psychiatric Association. Used with permission.
Evidence-based screening for POUD is pertinent for prevention and implementation of harm reduction and intervention strategies. Psychiatrists are well equipped and positioned to screen and assess for POUD and provide interventions as described below. There are numerous validated screening questionnaires that may be used to assess and monitor POUD, including the 4Ps Plus, National Institute on Drug Abuse Quick Screen, and CRAFFT (23). These screening tools may be used in the context of Screening, Brief Intervention, and Referral to Treatment (SBIRT), an evidence-based strategy that has been widely implemented across numerous medical settings including primary care and specialty clinics such as obstetrics and gynecology. The American College of Obstetricians and Gynecologists, American Medical Association, and the National Institutes of Health strongly support the use of this method of screening and treatment referral (24). Of note, urine drug screens are not a screening or diagnostic tool and should not be used to diagnose opioid use disorder or any other substance use disorder (23, 25).
For individuals who screen as positive on the above measures and/or through SBIRT procedure, opioid use disorder may be formally assessed and diagnosed with a clinical interview and monitored throughout treatment using validated self-report questionnaires. Modules from diagnostic interviews such as the Mini-International Neuropsychiatric Interview, Addiction Severity Index, or Substance Use Disorder Diagnostic Schedule may be used to assess the presence and severity of opioid use disorder and other substance use disorders. A clinical interview is suggested to be administered using patient-centered techniques such as motivational interviewing that embody a supportive, nonjudgmental, caring, encouraging, and honest approach (23, 26). Providers who desire additional training on motivational interviewing may consider the Motivational Interviewing—Foundational 6-week online course offered by Drs. William Miller, Theresa Moyers, and Stephen Rollnick (https://psychwire.com/motivational-interviewing/mi-foundational?utm_source=miller&utm_medium=homepage_banner), and the Motivational Interviewing Network of Trainers website, which has additional trainings, resources, and a worldwide network of members (https://motivationalinterviewing.org). Clinical interviews should be conducted in a safe, private space to ensure confidentiality.
Prescribers should be aware of the prescription drug monitoring program (PDMP), which is a state electronic database that tracks controlled prescriptions filled by pharmacies for individual patients. PDMP is a helpful tool in identifying patients who are filling prescriptions from multiple sources and for preventing co-prescribing of multiple opioid or central nervous system–depressing medications (e.g., opioids and benzodiazepines). Further, by utilizing PDMP and clinical interviews, providers can collaboratively explore patients’ prescription opioid and other prescribed medication (e.g., benzodiazepines) use that may be considered at risk of misuse. Examples include, but are not limited to, having multiple providers, refilling medication early, increasing dosage of medication over time, and/or overlapping prescriptions.
Within all screening and assessment tools mentioned previously, it is pertinent to remember that a pregnant person may fear the real possibility of legal and/or social services consequences, including losing custody of their child, after disclosing prenatal substance use. Providers who serve pregnant people who have substance use disorders need to be aware of their state’s laws regarding whether prenatal drug exposure is considered child abuse, whether they are mandated to report prenatal drug exposure including prescribed medications (i.e., MOUD) to child welfare services, and what methods of prenatal drug screening may result in a required report (e.g., urine drug screen vs. verbal report). See the Guttmacher Institute’s website (https://www.guttmacher.org/state-policy/explore/substance-use-during-pregnancy) for information on all 50 states and D.C.’s policies on substance use during pregnancy. Punitive policies that conflate substance use in pregnancy with child abuse and neglect have unintended consequences, including further stigma and marginalization, and serve as a barrier to disclosure of substance use and engagement with obstetric and behavioral health services. Nondisclosure of substance use in pregnancy has long-lasting impacts, including limiting access to treatment in the postpartum year, when birthing persons are at highest risk for overdose (27). Although MOUD is encouraged in pregnancy to manage POUD and prevent illicit opioid use and overdose, some states require automatic reports to child welfare services following delivery of infants who were exposed in utero to prescribed MOUD, which consequently places patients in a double bind when making treatment decisions (28, 29). To achieve equitable, accessible, and patient-centered care for persons diagnosed as having POUD, it is of paramount importance for MOUD prescribers to understand the complex landscape in which pregnant persons diagnosed as having opioid use disorder must navigate, and when health care recommendations may conflict with legal requirements.
In addition to fears of social and legal consequences of their illicit drug and/or MOUD use, patients often experience feelings of shame or perceived judgment by providers, which presents an additional barrier to prenatal substance use disclosure. To avoid further stigmatization and marginalization of patients, providers must be nonjudgmental and supportive both verbally and nonverbally when assessing and discussing prenatal substance use. Empowering patients with the knowledge of whether and at what time in gestation prenatal drug exposure is considered child abuse by their state’s laws, and discussing local procedures that will occur during their pregnancy, at delivery, and/or following birth as a result of prenatal drug use is paramount to instilling autonomy. Patients should be informed in this conversation that they must consent to providing a urine drug screen.
Pharmacotherapy for POUD
Psychiatrists are optimally positioned to prescribe buprenorphine to pregnant and postpartum people and, with the recent removal of the X-waiver, can greatly increase access to these evidence-based, lifesaving medications. Below we provide guidance on using shared decision-making methods with patients to arrive at the best individualized treatment plan, how to complete a buprenorphine induction, manage MOUD medication through pregnancy, and considerations of MOUD during labor and delivery, postpartum, and while chest/breastfeeding. Of note, buprenorphine as a monoproduct, as opposed to buprenorphine-naloxone, the combined product, was historically recommended for pregnant persons due to the theoretical risk of exposure to naloxone (14). However, it is increasingly recognized that the risk of exposure to naloxone in the combined product is only theoretical and accessing the monoproduct can be challenging and potentially place pregnant patients at risk of being targeted due to the street-value of the monoproduct. It is increasingly accepted in clinical practice to use the combined product (buprenorphine-naloxone) for pregnant people (14, 30).
Shared Decision Making
Like all good clinical practice, selecting a medication for POUD starts with shared decision making. Rooted in patient-centered care, shared decision making is a process by which health care providers engage patients in making decisions for their own care that are evidence-based and in line with patient preferences (31). It is critical that providers employ a shared decision-making approach when discussing POUD treatment options in order to support patient preferences. Pregnant women who are ambivalent about whether to taper or continue MOUD report that a shared decision-making conversation with their provider with the support of a shared decision-making tool helped them to make an informed decision that supported their values and preferences (32). This shared decision-making tool can be used to help patients decide whether to initiate or continue methadone or buprenorphine (32). See the online supplement for a shared decision-making tool for the treatment of perinatal opioid use disorder.
Psychiatrists may help patients interested in MOUD determine whether buprenorphine or methadone better fits their lifestyle and resources. Buprenorphine may be considered if the patient has had previous success with buprenorphine, is able to adhere to a less-structured outpatient therapy, and for patients who have limited access to transportation or childcare assistance. Methadone may be considered optimal if the patient has previously failed buprenorphine trials, had prior benefit from methadone, or would benefit from the greater structure and support offered by methadone treatment centers. At the time of this writing, two additional U.S. Food and Drug Administration–approved MOUD options are widely available: a monthly injectable formulation of buprenorphine and the opioid antagonist naltrexone, which comes in both a daily oral and monthly injection formulation. The monthly injectable formulation of buprenorphine is not indicated during pregnancy because the medication contains an excipient that is teratogenic based on animal data. Despite ongoing and current research, there are insufficient data to support the use of naltrexone for the treatment of POUD (30).
An additional consideration when treating POUD is conditions that commonly co-occur with opioid use disorder, namely chronic pain. Ultimately, both methadone and buprenorphine are efficacious in treating chronic pain and opioid use disorder. The best choice is typically the medication that demonstrates the most success in treating the patient’s substance use disorder. Providers should consider ease of access (e.g., daily travel to methadone clinics), history of the individual’s substance use disorder, previous success of methadone or buprenorphine, and cost of medication, as well as patient preference. Notably, in treating chronic pain, buprenorphine is correlated with lower withdrawal symptoms and less risk of toxicity with higher doses (33).
Medication-assisted withdrawal, or opioid taper or detoxification, is not recommended because it increases risk for relapse to substance use (34). Estimates of return to drug use vary substantially within studies (e.g., 14.3%–74.0%) (34). For example, a large systematic review found that rates of successful detoxification during pregnancy (9%–100%) and illicit drug use following detoxification (0%–100%) are widely variable (35). Medication-assisted withdrawal is also associated with poorer POUD treatment and labor and delivery outcomes relative to being stabilized on MOUD throughout the peripartum period (36). Although not recommended, shared decision making for patients who are interested in medication-assisted withdrawal should include a balanced discussion of risks and benefits of tapering off opioids, with attention to the risk of untreated POUD, including return to opioid use and harm due to intoxication and withdrawal cycles; poor adherence to prenatal care; and high-risk behaviors that are often associated with substance use (e.g., legal and social consequences, and infections due to unprotected sexual encounters or use of contaminated needles) (32, 37). Ultimately, the most successful treatment is the one that the birthing person is most confident in and that will help them to abstain from substance use or reduce engagement in risky substance use.
Education on Risks and Benefits of MOUD and Untreated POUD
As part of the shared decision-making process, psychiatrists should provide education about the risks and benefits of medications for POUD and discuss all treatment options prior to MOUD initiation, including the risks of untreated POUD. Risks of using buprenorphine or methadone during pregnancy include NOWS, preterm birth, and low birth weight (of note, these risks are also risks of untreated illness). See Table 1 for a comparison of risks and benefits of buprenorphine, methadone, and untreated POUD.
| | Methadone | Buprenorphine | Untreated POUD |
|---|---|---|---|
| Risks | NAS (69.2%) | NAS (52.0%) | NAS (70.1%) |
| | Preterm birth (24.9%) | Preterm birth (14.4%) | Adverse fetal outcomes, i.e., preterm birth, low birth rate, small for gestational age, placental abruption, premature rupture of membranes |
| | Low birth weight (14.9%) | Low birth weight (8.3%) | Adverse pregnancy outcomes including severe preeclampsia or eclampsia and pregnancy-related death |
| | Small for gestational age (15.3%) | Small for gestational age (12.1%) | Higher risk of fatal and nonfatal overdose |
| | State dependent child welfare involvement | State dependent child welfare involvement | Risk of hepatitis, sepsis, and cellulitis |
| | Higher risk of sedation and overdose, especially when used with other CNS depressants (e.g., opioids, benzodiazepines, alcohol) relative to partial opioid agonists (buprenorphine) | Risk of sedation and overdose, especially when used with other CNS depressants (e.g., opioids, benzodiazepines, alcohol) although generally lower than full opioid agonists (e.g., methadone) | Social consequences including stigma, prostitution, exposure to violence |
| | Requires daily in-person attendance to outpatient treatment program | Requires attendance to an outpatient clinic appointment in-person or via telehealth, depending on federal and state regulations | State dependent child welfare involvement, and/or legal consequences |
| | | | Opioid exposure through breast milk; chest/breastfeeding not recommended |
| Benefits | Recommended for use during pregnancy and while chest/breastfeeding | Recommended for use during pregnancy while chest/breastfeeding | There are no medical benefits to untreated POUD to either the mother, fetus, or newborn. |
| | Lower risk of relapse to opioid use, overdose, and death | Lower risk of relapse to opioid use, overdose, and death | |
| | Reduces harmful substance use behaviors and increases functioning | Reduces harmful substance use behaviors and increases functioning | |
| | Lower rates of NAS compared with untreated POUD | Lower rates of NAS compared with untreated POUD | |
| | Structure of outpatient treatment program can be beneficial for some patients | Available as an outpatient prescription by any provider with a DEA license | |
a
CNS, central nervous system; DEA, Drug Enforcement Administration; NAS, neonatal abstinence syndrome; POUD, perinatal opioid use disorder.
NOWS is an expected and treatable condition among infants who had prenatal exposure to illicit opioids and opioid agonists. There are no known long-term risks associated with NOWS, including developmental problems (38). NOWS symptoms typically appear 1–3 days after birth but may begin 2–4 weeks after birth and are characterized by a high-pitched cry, tremors, sweating, poor feeding, and gastrointestinal upset. Buprenorphine demonstrates a slightly lower incidence of NOWS compared with methadone, but risk of adverse maternal outcomes, including cesarean section and severe maternal complications, were similar for buprenorphine and methadone (see Table 1) (39). It is important to convey to patients that the risk for NOWS is not related to the dose or duration of prenatal MOUD and that there are both pharmacological and nonpharmacological treatments for NOWS (see the “Considerations for Labor and Delivery” section). Despite the risks associated with MOUD, use of illicit opioids places the birthing person and neonates at greater risk for poor obstetric, fetal, and social outcomes (see Table 1) (11, 23, 34).
MOUD Induction Considerations
Buprenorphine induction historically occurred in outpatient clinics, but at-home inductions are increasingly being done to reduce barriers to initiation and improve access to treatment (40). Patients electing at-home buprenorphine inductions need to be provided with clear dosing instruction to ensure medication adherence and to properly facilitate the induction in order to avoid precipitated withdrawal. Precipitated withdrawal is the rapid and intense onset of opioid withdrawal after recent opioid agonist exposure due to administration of buprenorphine or an opioid antagonist and is particularly common among people who use fentanyl. Patients need to exhibit clinically significant signs and symptoms of opioid withdrawal prior to administration of the first dose of buprenorphine or they will experience precipitated withdrawal. Providers and patients can use the Clinical Opiate Withdrawal Scale (COWS) to ensure that patients are experiencing adequate withdrawal symptoms prior to initiation of buprenorphine (41). A COWS score of 8–12 is adequate; higher scores are better for those who primarily use synthetic opioids, i.e., fentanyl.
Currently, methadone is initiated and managed within Substance Abuse and Mental Health Services Administration (SAMHSA)-certified opioid treatment programs and does not require the patient to be experiencing withdrawal symptoms. The COVID-19 era policy changes that allow take-home methadone doses catalyzed conversations among patients and providers alike and demonstrated increased access to lifesaving medication and improvements in patient satisfaction and patient-centered care, without evidence of increased diversion and misuse (42). Although some providers are in full support of permanent policy expansions to allow take-home methadone doses, others express hesitation due to the inability to physically assess patients, including regular drug screening, and the resulting subjectivity of deeming a patient “stable” enough to receive their take-home dose (where stability typically translates to abstinence from drugs and alcohol) (43, 44). Although permanent expansion of take-home methadone is not currently a reality, it may be beneficial for providers to be aware of these patient and prescriber perspectives, always keeping in mind the patient’s right to autonomy in their medical treatment when discussing medication options.
As discussed previously, the opioid antagonist naltrexone is not currently considered the standard of care for POUD. Although there is research being conducted, there is not currently sufficient evidence to recommend extended-release injectable or oral naltrexone during pregnancy. Pregnant persons should be informed of the limited data and offered treatment with buprenorphine or methadone. If the pregnant person is unable to engage with buprenorphine or methadone due to previous ineffective trials or inability to access these medications, they should be switched to oral naltrexone. Most studies have investigated the oral form of naltrexone during pregnancy and the oral preparation can be quickly discontinued so that pain can be optimally managed during labor and delivery (14). Some pregnant women may be stabilized on buprenorphine or methadone prior to becoming pregnant, and it is recommended to maintain this medication throughout pregnancy and following delivery (relative to switching from one to the other). The dose of methadone or buprenorphine will need to be adjusted over the course of pregnancy in response to craving and withdrawal symptoms. Pregnant women often require a higher MOUD dose or more frequent dosing relative to their preconception dose given the physiological changes that occur during pregnancy (45, 46).
There are special considerations for MOUD induction for pregnant people who use synthetic opioids, i.e., fentanyl. Fentanyl’s pharmacokinetics differ from other opioids, such that prolonged use can result in increased fentanyl distribution volume within the body and slow dissipation (47, 48). These properties result in significant difficulty in maintaining opioid abstinence long enough to initiate buprenorphine and can increase the incidence of precipitated withdrawal while attempting induction. Still, buprenorphine is a good candidate for POUD treatment, especially in the case of fentanyl use, as it provides additional overdose prevention relative to methadone, which is a full opioid agonist. A relatively new outpatient buprenorphine induction approach, termed the Bernese method (colloquially referred to as buprenorphine “microdosing”), may mitigate the barrier of requiring opioid abstinence prior to buprenorphine induction. Microdosing involves prescribing buprenorphine in a small dose initially (e.g., 0.5 mg) with incremental increases in dose and frequency over time. Concurrently, the patient may continue to use other opioids in decreasing amount and frequency until a therapeutic dose of buprenorphine is reached (typically >8 mg daily), at which point full opioid agonists such as fentanyl are discontinued (48). The microdosing process occurs over approximately 7–10 days and is reported to be well tolerated and can successfully prevent precipitated withdrawal (49). See Table 2 for a list of provider resources for MOUD induction and pharmacological management of POUD.
| Resource | Format | Source | Description and features |
|---|---|---|---|
| Clinical Guidance for Treating Pregnant and Parenting Women with Opioid Use Disorder and Their Infants | Downloadable PDF: https://store.samhsa.gov/sites/default/files/d7/priv/sma18-5054.pdf | Substance Abuse and Mental Health Services Administration (SAMHSA), 2018. HHS publication no. (SMA) 18–5054 | Detailed guidance on screening and treatment of pregnant and postpartum people diagnosed as having opioid use disorder, including considerations for MOUD initiation, maintenance, titration and tapering for pregnancy, labor/delivery, postpartum, and chest/breastfeeding, as well as infant care related to screening, management, and intervention of NOWS. |
| Training requirements (MATE Act) resources | https://www.samhsa.gov/medications-substance-use-disorders/training-requirements-mate-act-resources | Substance Abuse and Mental Health Services Administration (SAMHSA) | SAMHSA funds the Providers Clinical Support System (PCSS) to provide practitioner training in the evidence-based prevention and treatment of opioid use disorder and offers the trainings needed to apply for DEA registrations to prescribe Schedule II–V medications. SAMHSA offers tools, training, and technical assistance to practitioners in the fields of mental and substance use disorders. Find information on SAMHSA training and resources. |
| BUP Initiation | Mobile application | Amston Studio LLC, 2021. Available at no cost for iOS and Android. | Designed for health care providers who are working in acute care settings to assist with buprenorphine induction. Guides provider through an assessment of opioid use disorder based on DSM-5 criteria, COWS to assess opioid withdrawal, brief MOUD negotiation interview, and provides tailored MOUD recommendations related to dosing and naloxone distribution. |
| Buprenorphine Home Induction Tool | Mobile application | Department of Veterans Affairs, 2020. Available at no cost for iOS and Android. | Guides patients through sublingual buprenorphine inductions at home; intended to be used in conjunction with direction from a prescriber. Users are provided step-by-step instructions for each day of buprenorphine induction, including their personal dosage information, when to take the initial dose, how to take buprenorphine properly, and general information about buprenorphine. |
| BMC MAT Quick Start | Mobile application; material available as PDF downloads | Boston Medical Center Corporation, 2023. Available at no cost for iOS and Android. | Created following the removal of the X-waiver requirement, this app is designed for all health care providers who are treating patients diagnosed as having opioid use disorder and alcohol use disorder. Includes education, tools, patient handouts, and clinical decision-making algorithms for buprenorphine and naltrexone induction, as well as pain management guidelines within the context of opioid and alcohol use disorders. |
| Project ECHO opioid use disorder telementoring and educational sessions | Teleconferencing meetings | Several academic medical centers throughout the country host ECHOs for perinatal substance use. | Resource for health care providers who are currently providing MOUD for opioid addiction and for practitioners who are interested in learning more about how to become a MOUD provider in their community. Telementoring support is provided to current and future MOUD providers across the state of South Carolina. Brief, user-driven didactic content-relevant opioid use disorder and office-based MOUD, delivered by national experts in the treatment of opioid use disorder. |
| State Perinatal Psychiatry Access Programs | https://www.postpartum.net/professionals/state-perinatal-psychiatry-access-lines | Postpartum Support International | Perinatal psychiatric consultation service for providers of pregnant and postpartum people who are diagnosed as having psychiatric and substance use disorders. Providers can research the program within their state and call for provider-to-provider case consultation. |
| Practice Pathway–Addiction Medicine certification | https://www.asam.org/education/addiction-medicine-certification/certification-pathways-new | American Society of Addiction Medicine | There are several pathways for physicians to become certified addiction medicine specialists. Visit the website to determine whether you are eligible and qualified to be certified by the Addiction Medicine boards. |
a
COWS, Clinical Opiate Withdrawal Scale; ECHO, Extension for Community Healthcare Outcomes; MOUD, medication for opioid use disorder.
MOUD Maintenance Considerations
MOUD dose increase is likely to be needed throughout pregnancy, especially if patients are experiencing craving and/or withdrawal symptoms (46). For those receiving buprenorphine, prescribers may instruct patients to split their total daily dose as a first step. For example, a patient whose dose is 16 mg buprenorphine daily may split their dose: 8 mg are taken in the morning and 8 mg are taken in the evening. If craving or withdrawal symptoms continue, a dose increase of 4–8 mg is recommended with the goal of eliminating withdrawal and craving symptoms. It is important to also optimize any needed additional psychiatric or behavioral health interventions such as additional pharmacotherapy, psychotherapy, and/or peer support.
It is important to understand that recurrent opioid use despite negative physical and psychosocial consequences is characteristic of opioid use disorder (see Box 1). As such, it is expected that pregnant and postpartum patients receiving MOUD may experience lapses and/or return to drug use while engaged in a treatment program under the care of a psychiatrist. Patients should not be discharged from treatment due to substance recurrence; rather, recurrence is an opportunity to problem-solve with the patient, strengthen coping skills, and assess whether additional support is needed. Collaborative discussions to identify solutions to substance recurrence that bolster the patient’s confidence and autonomy in recovery will also offer an opportunity to build trust and rapport with the provider.
Considerations for Labor and Delivery
Methadone or buprenorphine should not be discontinued or reduced during labor and delivery but should be continued without interruption to ensure stability and prevent withdrawal symptoms. It is important to note that MOUD is not adequate for providing analgesia during labor and delivery. Patients taking MOUD should be offered, at minimum, the same pain management regimen as patients not taking MOUD. Due to opioid exposure, pregnant people diagnosed as having POUD may have a high tolerance to opioids and/or opioid-induced hyperalgesia, which can result in severe pain in the immediate postpartum period (50). Acute pain management in the peripartum period must be multimodal and include the use of full opioid agonists such as fentanyl and potentially in higher doses than for patients who do not have a history of opioid use disorder (14, 30). Certain patients may be concerned about their pain management during delivery; it may be necessary to arrange consultation with the anesthesiologist prior to labor, and patients can be encouraged to visit their labor and delivery unit to tour and learn how NOWS and their pain will be managed (14).
A review and discussion of the possibility, management, and consequences of NOWS is warranted prior to labor. Infants who have more severe NOWS symptoms may require pharmacological treatment such as morphine. Nonpharmacological approaches are also effective, such as rooming-in and, when appropriate, chest/breastfeeding, the latter of which can reduce NOWS severity and the need for pharmacological treatment. An evidence-based assessment tool and nonpharmacological intervention for NOWS is Eat, Sleep, Console (ESC), which involves chest/breastfeeding (when appropriate), skin-to-skin contact, swaddling, and low-stimulation environments, as well as parental involvement in the assessment and care of their infant. ESC has been shown to significantly reduce the number of days until infants who experienced NOWS were medically ready for discharge relative to the standard of care (8.2 vs. 14.9 days) (51). Additionally, it is important for patients to know where they are delivering, and that lactation consultants and a pediatric team will be available in that setting to help with chest/breastfeeding and monitoring and treating NOWS, respectively.
Chest/breastfeeding is recommended for patients who are receiving buprenorphine and methadone in most cases, except for patients with HIV or who have high viral loads of hepatitis. Patients who have a history of hepatitis C are encouraged to chest/breastfeed. Patients who are considering tapering MOUD because of concern about opioid agonist exposure through breast milk should be assured that the amount of exposure is extremely small and the risk to the birthing person and infant is greater in the context of return to substance use (14). Due to a lack of current clinical evidence regarding the safety of infants, chest/breastfeeding is not currently recommended for patients who are receiving naltrexone.
Considerations for the Postpartum Period
The first postpartum year is considered to be a high-risk time for complications from substance use, mental health, and social drivers of health, culminating in increased risk for return to opioid use and opioid overdose (27). As such, continued use of MOUD during the first postpartum year is critical for reducing the risk for opioid recurrence and overdose. A patient’s dose may need to be evaluated and possibly reduced relative to their dose during pregnancy to maintain similar buprenorphine or methadone exposure after delivery (45). Patient reports of somnolence and drowsiness are indicators that the MOUD dose may need to be decreased. However, in cases of concurrent substance use, mental health issues, or significant social stressors, MOUD dose may need to be increased during the postpartum period to enhance stability and prevent withdrawal symptoms or cravings. Due to risk of destabilization, it is not recommended to change opioid use disorder pharmacotherapies in the postpartum period unless clinically indicated. Breakthrough cravings or withdrawal symptoms can be addressed by adjusting the current medication regimen (e.g., increase dose or frequency of administration). Like medication management of other chronic diseases, MOUD can be continued indefinitely throughout the patient’s life to manage opioid use disorder and reduce risk for overdose and other adverse outcomes.
Conclusions
In summary, psychiatrists have an important role in the delivery of MOUD for perinatal opioid use disorder and reducing maternal mortality due to drug overdose. Medication treatment decisions should follow a shared decision-making process during which treatment decisions are based on the best evidence to date and the patient’s preferences and values. While consideration of the impact of MOUD on newborn outcomes can be considered, medication choices should be driven by what is best for maternal health. Buprenorphine inductions can be safely completed during pregnancy and postpartum, and dose adjustments should be based on patients’ reports of craving and/or withdrawal symptoms. Visiting the delivery hospital prior to labor and delivery to discuss practices for pain management, NOWS, and standard protocols for notifications to the department of social services can be very helpful in addressing any anticipatory anxiety and yielding the best possible maternal and newborn outcomes. During the postpartum period, chest/breastfeeding should be encouraged, MOUD should be continued, and plans for maternal postpartum care and support should be prioritized as support and stress-reduction is critical to maintaining recovery, preventing relapse, and ensuring short- and long-term mother-infant bonding and connection (52).
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Information & Authors
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Published in print: Winter 2024
Published online: 16 January 2024
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Competing Interests
Dr. Guille reports being a Visiting Scientist for and receiving consulting honorarium from Maven Clinic—an online women’s and family health platform. The other authors report no financial relationships with commercial interests.
Funding Information
Supported by NIDA grant K12 DA031794 (to Dr. Witcraft) and the Patient-Centered Outcomes Research Institute grant IHS-2021C3-24493 (to Dr. Guille). Additional support was received from NIDA and Office of Research on Women’s Health as part of a Specialized Center of Research Excellence on Sex Differences through grant U54DA016511 and NIDA Clinical Trials Network through grant UG1DA013727 (to Dr. Guille). None of the funding sources had a role in the preparation, review, or approval of the manuscript, or the decision to submit the manuscript for publication.
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