The management of pregnancy and delivery of a woman on opiate-substitution therapy with buprenorphine requires a coordinated team approach by social services, addiction medicine, obstetrics, and pediatrics. Her obstetrical care is further complicated by the unique pharmacology of buprenorphine and the issues of pain management. Obstetrical providers should be familiar with the complex issues surrounding the optimal care of these women.
An estimated 2.25 million people in the United States are dependent on or abusing opiates. Women have a higher rate than men for addiction to prescription pain relievers. Substance abuse admissions for the treatment of prescription opiate addiction have increased nearly 4-fold since 1998. Among women aged 15-44 years, 10.6% used illicit drugs in the past month based on 2008-2009 self-reported survey data. Among women 15-25 years old, the use was higher, 7.1-15.8%. The rate was considerably lower in those who were pregnant (4.5%), but a substantial and very likely increasing number of women continue to use drugs in the peripartum period.
The general management of opiate dependency inside or outside pregnancy is grounded on psychosocial treatment including: self-help and 12 step groups, individual and group substance abuse counseling, and psychotherapy. To minimize or eliminate exposure to infectious diseases, reduce the risk of accidental overdose, and support a therapeutic environment conducive to recovery, opiate detoxification followed by abstinence or opiate-substitution maintenance is recommended. In the United States, methadone and buprenorphine are the only opiate-substitution medications approved for the treatment of opiate addiction. Both also have been used for medically supervised opiate withdrawal and detoxification, but results are disappointing because long-term abstinence is low. For the majority of opiate-addicted women, opiate-substitution programs combined with psychosocial treatment offer the best chance of stabilization of their addiction and opportunity for a sustainable recovery.
Opiate-substitution programs provide methadone through designated licensed clinics or buprenorphine through specifically trained and federally waivered physicians. Increasing demand for the treatment of opiate addiction has driven the buprenorphine/naloxone combination (Suboxone; Reckitt Benckiser Pharmaceuticals Inc., Richmond, VA) to the 41st most prescribed drug in the United States in 2009, a year in which annual sales increased 68.1% to 5.7 million prescriptions. Prescriptions of buprenorphine monotherapy (Subutex [Reckitt Benckiser Pharmaceuticals, Inc.] and generic), used primarily for the treatment of pregnant women, numbered approximately one-third million in 2009.
During pregnancy, methadone (category B) is the recommended substitution treatment for opiate addiction and is considered the standard of care. If methadone treatment is refused or unavailable, then opiate-substitution management with buprenorphine may be considered after informed consent is obtained and the risk of inadequate experience in pregnancy is clearly documented. The literature that reports buprenorphine maintenance in pregnancy is limited but growing, and buprenorphine has recently been advocated as a first-line therapy.
There are 6 studies that report comparisons between buprenorphine and methadone-treated pregnant women and their infants. Compared with methadone, buprenorphine-treated pregnant women had similar cesarean section rates, maternal weight gain, and number of prenatal visits. Medical complications were lower in buprenorphine-treated women, and overdoses were less frequent than with methadone. Retention rates until delivery were variable. Rates of neonatal abstinence syndrome were the same as or lower in the buprenorphine group and hospitalizations shorter. Birthweights were similar or higher for infants in the buprenorphine group, whereas Apgar scores were not significantly different. Duration of newborn hospitalization was significantly shorter in the buprenorphine-treated group.
The available evidence supports the use of buprenorphine in the treatment of opioid-addicted pregnant women. It appears to be a suitable alternative to methadone in the maintenance of maternal addiction, with most researchers reporting a shorter and milder abstinence syndrome in the neonate.
Barriers to treatment
There are a number of barriers to the management of opiate abuse in pregnancy. The social stigma, guilt, and shame of ongoing drug addiction during pregnancy may pressure the woman into attempting to quit using opiates on her own or denying or hiding the problem until delivery. One fear is that seeking treatment for her opiate addiction will result in mandatory reporting and attract the attention of government social service and health authorities. Interventions, including the monitoring of herself, her partner, and the condition of her other children, are not always welcome. Poor self-esteem, a low level of education, and legal problems are common in opiate users and interfere with self-reporting and seeking assistance.
Economic barriers include the cost of missed employment to attend rehabilitation sessions in addition to child care and transportation expenses. Housing security is often tenuous and staying with friends or being homeless may place the women back into the drug subculture they are trying to escape.
The partner’s continued use of illicit drugs can be an insurmountable problem because the woman may be caught between the need for emotional and financial support with the continued temptation to relapse and the risk of social service intervention to remove a drug user from the household. Ongoing mental and physical abuse may complicate the relationship. Family dysfunction may include addicted future grandparents. There is also a higher prevalence of psychiatric disease and chronic medical illnesses in this population. Posttraumatic stress disorder because of prior sexual abuse is common among opiate users.
In some areas access to opiate-substitution therapy is limited by distance, waiting lists, or a shortage of licensed buprenorphine prescribers. Pregnant women can expect priority acceptance into most treatment programs. Opiate-addicted maternal-infant dyads should be delivered in a medical center with physicians and nurses experienced in their assessment and management. Treatment compliance and pregnancy outcomes are improved when addiction and obstetrical care are delivered at the same location.
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