Narcotics encompass the class of drugs known as opiates (naturally occurring alkaloid compounds found in opium [eg, morphine, codeine, thebaine]) and opioids (semisynthetics/synthetics [eg, heroin, hydrocodone, oxycodone, buprenorphine, methadone, fentanyl]). They have an important role in patient care, serving to manage acute pain associated with surgery or injury and chronic pain as encountered in palliative care.

Narcotics have a high abuse potential. Historically this abuse has been associated with the use of the illicit opiate, heroin. There has been an increasing trend in the chronic use of prescription opioids and diversion of these drugs for abuse in the United States. People addicted to prescription opioids are 40 times more likely to be addicted to heroin. It is reported that 75% of new heroin users have used opioids prior to initiating heroin use and that heroin’s lower price, increased purity, and availability could contribute to this trend.

In the past, physicians did not pay as much attention to a patient’s need for pain relief outside acute pain or palliative care pain. In his 1995 Presidential Address to the American Pain Society, James Campbell introduced the concept of pain as “the fifth vital sign” to bring attention to the fact that physicians do well with treating acute pain and cancer pain but not with management of noncancerous pain, and this may not serve patients well.

The Veterans Health Administration recognized the need to manage noncancerous pain and in 1998 initiated a National Pain Management Strategy. Assessment of patient satisfaction with their health care has become an increasing measure of the quality of medical care and a part of physician compensation.

In considering patient satisfaction as a measure of the quality of their care, physicians may be more likely to provide services (diagnostic tests, drug prescriptions) that are not indicated to assure patient satisfaction. About 40% of the adult American population suffers from chronic pain. Between 2006 and 2012, there were 47 million to 62 million prescriptions per quarter for opioid analgesics dispensed.

Whereas this might seem to be recognizing and treating chronic pain, there is a price to pay. In addition to the risk of becoming addicted to heroin, the yearly prescription opioid-related deaths have been increasing from about 17,000 in 2010 to 19,000 in 2014. Patients who are more satisfied with their medical care are also more likely to die.

It was not the intent of pain as the fifth vital sign to mean that everyone with pain should take an opioid. Recently the Centers for Disease Control and Prevention, the Food and Drug Administration, and individual states have enacted guidelines or prescription monitoring programs to address the opioid epidemic. It will take time for the impact of these measures to be realized.

Opioid abuse during pregnancy is associated with a variety of adverse pregnancy outcomes (eg, fetal growth impairment, premature rupture of membranes, preterm labor, abruption, sexually transmitted diseases) and its use has been increasing during pregnancy. After delivery a continuing risk to the infant of neonatal abstinence syndrome requiring treatment ranges from 45% to 97%. More term infants require treatment (81%) compared with preterm infants (58%).

Detoxification of patients from opioids has the benefit of avoiding the complications of addiction. Although readily considered in nonpregnant patients, detoxification during pregnancy had been hindered by 2 reports that provided limited proof of danger to the fetus.

The report by Rementeria and Nuang described a heroin-addicted mother who underwent multiple methadone maintenance attempts but reverted to heroin use. The night before delivery, she treated several hours of withdrawal symptoms with a heroin injection before arriving at the hospital, but the admission examination noted a fetal demise.

The authors also summarized 7 perinatal deaths among 47 drug-addicted mothers over an 18 month period of time. It was not known whether any of the mothers had withdrawal symptoms during pregnancy in 71% of the cases. The report by Zuspan et al described a case of a patient being tapered off methadone maintenance and undergoing serial amniocentesis to assess amniotic fluid amine levels (epinephrine and norepinephrine). After methadone doses were lowered, an amniocentesis was performed. On 2 occasions the amine levels increased above the amine levels at the first amniocentesis. After the second time the amine level increased, the methadone dose was increased from 10 mg/d to 15 mg/d and 2 weeks later, the amniotic amine levels were stable.

Since 1990, there have been periodic reports of experience with maternal opioid detoxification during pregnancy that have challenged the prior cautions against detoxification and opened the door to this treatment for pregnant women.

In this issue of the Journal, Bell et al report results of a retrospective evaluation of their experience with opioid detoxification of pregnant women over the past 5-6 years. In Tennessee there are about 1000 infants a year who require treatment for neonatal abstinence syndrome. Because of health care concerns with this epidemic, the authors’ institution promoted a program for opiate detoxification. No one report can address all the issues involved with opioid detoxification.

The authors focused on 4 outcomes: fetal demise, fetal distress, preterm labor, and neonatal abstinence syndrome. The 301 patients in this report comprised 4 detoxification groups: group 1 (involuntary because of incarceration), group 2 (5–8 days of inpatient detoxification with an outpatient behavioral health follow-up), group 3 (5–8 days of inpatient detoxification without an outpatient behavioral health follow-up), and group 4 (8–16 weeks of outpatient detoxification with an outpatient behavioral health follow-up).

The only 2 cases of fetal death occurred in group 1 at 8 weeks and 22 weeks after detoxification. Maternal drug screens were negative, and thus, the fetal deaths would not be attributable to detoxification. The relapse rate was 17.4% to 23.1% with a neonatal abstinence syndrome rate of 17.2% to 18.5% (groups 1, 2, and 4) vs a relapse rate of 74% and a neonatal abstinence syndrome rate of 70.1% for group 3.

This highlights the importance of a long-term support program to lessen these setbacks. The neonatal abstinence syndrome rates were low, but all occurred in patients who had relapsed. The preterm birth rate was 17.6%.

The authors fell short on their assessment of fetal distress as part of their primary outcome of determining whether detoxification is harmful to the fetus. This is because fetal monitoring was not undertaken during the detoxification process. This aspect is important and would be helpful information to know. If other institutions develop a program similar to the authors’ but do use fetal monitoring during detoxification and encounter fetal distress, a delivery intervention might occur with a resultant preterm infant.

The authors’ experience shows a similar benefit and safety to detoxification as shown in other reports. However, there is also an important difference in their experience. Group 1 had the largest number of patients (108, 36%) and unlike the other groups did not have the benefit of medication-assisted detoxification because the Tennessee penal system did not have the ability to provide this treatment.

Unintentionally, group 1 treatment also questions the concern about fetal risk to detoxification raised by reports in the 1970s. In terms of fetal harm reflected by a risk of fetal demise, the authors add to the reported experience that detoxification seems safe. They also open the door a bit more to the likelihood that involuntary detoxification of incarcerated patients might occur in other penal systems. Knowing what the outcomes are in other penal systems could provide valuable information about risk to the fetus when acute detoxification is not medication assisted.

This report demonstrates that the authors have developed a program that should have a beneficial impact on the large number of infants requiring treatment for neonatal abstinence syndrome at their institution. As the authors point out, it is not just providing the medicine-assisted detoxification, but also doing so with medical guidance and continued behavioral support to lessen failure relapse and keep neonatal abstinence syndrome rates low is also critical to success.