buprenorphine and Labor-Pain

We review clinical care issues that are related to illicit and therapeutic opioid use among pregnant women and women in the postpartum period and outline the major responsibilities of obstetrics providers who care for these patients during the antepartum, intrapartum, and postpartum periods. Selected patient treatment issues are highlighted, and case examples are provided. Securing a strong rapport and trust with these patients is crucial for success in delivering high-quality obstetric care and in coordinating services with other specialists as needed. Obstetrics providers have an ethical obligation to screen, assess, and provide brief interventions and referral to specialized treatment for patients with drug use disorders. Opioid-dependent pregnant women often can be treated effectively with methadone or buprenorphine. These medications are classified as pregnancy category C medications by the Food and Drug Administration, and their use in the treatment of opioid-dependent pregnant patients should not be considered "off-label." Except in rare special circumstances, medication-assisted withdrawal during pregnancy should be discouraged because of a high relapse rate. Acute pain management in this population deserves special consideration because patients who use opioids can be hypersensitive to pain and because the use of mixed opioid-agonist/antagonists can precipitate opioid withdrawal. In the absence of other indications, pregnant women who use opioids do not require more intense medical care than other pregnant patients to ensure adequate treatment and the best possible outcomes. Together with specialists in pain and addiction medicine, obstetricians can coordinate comprehensive care for pregnant women who use opioids and women who use opioids in the postpartum period.

Topics: Analgesics, Opioid; Buprenorphine; Confidentiality; Dose-Response Relationship, Drug; Emergency Service, Hospital; Female; Humans; Labor Pain; Labor, Obstetric; Mental Disorders; Methadone; Narcotic Antagonists; Opiate Substitution Treatment; Opioid-Related Disorders; Pain, Postoperative; Physician-Patient Relations; Postnatal Care; Pregnancy; Pregnancy Complications; Prenatal Care; Referral and Consultation; Triage

To determine whether buprenorphine maintenance alters intrapartum or postpartum pain or medication requirements.. Sixty three patients treated with buprenorphine for opioid dependence during pregnancy (vaginal n = 44; cesarean n = 19) were matched retrospectively to control women. Analgesic medication and pain scores (0-10) were extracted from the medical record. Primary endpoint: opioid utilization postpartum (oxycodone equivalents). Secondary endpoints: pain scores and intrapartum analgesia.. There were no differences in intrapartum pain or analgesia. Following vaginal birth, buprenorphine maintained women had increased pain (buprenorphine 2.7 (1.7,4.0); control 2.1 (1.2,3.0), p = 0.006) but no increase in opioid utilization (buprenorphine: 11.8 ± 24.8; control 5.4 ± 10.4 mg/24 h, p = 0.10); following cesarean delivery both pain (buprenorphine: 5.1 (4.1,6.1); control: 3.3 (2.5,4.1), p = 0.009) and opioid utilization (buprenorphine: 89.3 ± 38.0, control: 60.9 ± 13.1 mg/24 h, p = 0.004) were increased.. Buprenorphine maintained women have similar intrapartum pain and analgesic needs during labor, but experience more postpartum pain and require 47% more opioid analgesic following cesarean delivery.

Topics: Adult; Analgesics, Opioid; Buprenorphine; Cesarean Section; Cohort Studies; Female; Humans; Labor Pain; Narcotic Antagonists; Outcome Assessment, Health Care; Pain, Postoperative; Postpartum Period; Pregnancy; Retrospective Studies; Young Adult