This section provides additional information for medication initiation during pregnancy. For detailed information about initiation of medication, patient selection, or other issues related to the initiation of buprenorphine, see the Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction[1]
Medication should not be initiated until both opioid dependence and a viable intrauterine pregnancy (ultrasound with heartbeat) are confirmed. Pregnancy is an indication for priority treatment but is not an emergency.
For initiation of medication during pregnancy, there must be a diagnosis/confirmation of pregnancy. Home pregnancy tests (i.e., urine tests) are not sufficient for initiation of treatment. A viable intrauterine pregnancy should be confirmed by an obstetric providers or community health clinic.
For a diagnosis/confirmation of physical opioid dependence, a urine test for opioids can be run as either an office-based point-of-care test or a laboratory test. Physical opioid dependence should be documented by the presence of opioid withdrawal symptoms, using a tool such as Clinical Opiate Withdrawal Scale (COWS) found in Appendix 8. In addition, query of the North Carolina Controlled Substances Reporting System (CSRS) to assess prescription opioid use is recommended. Occasional use of opioids may not cause physical dependence, and therefore, might not require agonist therapy; however monitoring is imperative.
While a woman may have previously been physically opioid dependent, any period of abstinence, including involuntary abstinence due to jail or other institutionalization, needs to be determined through careful assessment, including laboratory tests and establishing opioid withdrawal symptoms.
Methadone or Buprenorphine Initiation
The provider, in consultation with the woman, should decide on the medication of choice. Induction of medication will follow the same procedure used in your practice for patients who are not pregnant; pregnant women should be considered a priority induction, with a goal of initiation of medication within one week of the medication decision.
Mild or even moderate symptoms of opioid withdrawal (CINA 10-12 range, See Appendix 7) are not dangerous to pregnancy. For the purposes of medication induction, it is reasonable to ask the woman to abstain from opioid use (and have withdrawal symptoms). Buprenorphine mono-therapy (Subutex) is recommended during pregnancy.[2]
Continuation of Medication during Pregnancy
(After induction or in a person who was previously stable on medication):
If buprenorphine is being used, change to buprenorphine monotherapy at the same dose.
- Assess for withdrawal symptoms weekly (see Medication Provider Visit Flow Sheet, Appendix 9) and adjust dose of buprenorphine as indicated; one refill (total of 2 weeks of medications) may be considered for the stable woman in counseling.
- To minimize diversion/theft/loss of medication, provide only one week of buprenorphine medication at a time
Pregnancy-specific dosing notes:
- 70% of patients stable prior to pregnancy will need a modest dose increase of buprenorphine (3-5 mg) during pregnancy[4], which should be prescribed gradually throughout gestation. This is due to the increase in blood volume through the pregnancy.
- The average buprenorphine dose at the end of pregnancy is 16 mg[1] for women who began buprenorphine treatment during pregnancy.
- Large increases in buprenorphine requirements have not been noted during pregnancy; if such increases are needed, consider alternative diagnoses.
- If the woman is in office-based buprenorphine treatment and has difficulty in engaging in ancillary services and counseling, consider switching her to an opioid-treatment program.
- If methadone is being used, very high doses of methadone might need to be split, due to increased[2]
Pregnancy Management for the Medication Provider:
At Initiation of Pregnancy Care:
If a pregnant woman is insured with Medicaid, you should refer the woman to your region’s Community Care of North Carolina (CCNC) Pregnancy Care Manager (PCM). See the “Services for Women with Opioid Exposed Pregnancies in North Carolina” for the agency in your region that houses the CCNC PCM (typically the county health department). After the referral, continue to see the patient in weekly visits and for urine drug screens.
The stress of pregnancy and having a newborn warrant closer follow-up, even if the woman has not needed substance-use disorder counseling in the past. Weekly monitoring with urine toxicology screens is recommended. Obtain HIPAA-compliant and 42 CFR Part 2-compliant consents to permit communication with the woman’s obstetric provider, counselor, and planned pediatric provider. Communication is essential between the caregivers for the woman, in order to provide the best care possible. Ideally this consent will be obtained at the onset of treatment. (See Appendix 1 for samples).
Contact the obstetric provider and pediatric provider directly to document medication (methadone or buprenorphine) use in pregnancy. You should also consider which hospital in the region is best able to manage delivery and potential neonatal needs. Refer to the “Services for Women with Opioid Exposed Pregnancies in North Carolina”. Document the woman’s estimated due date (patient self-report is sufficient).
Recommendations for Weekly Buprenorphine Office Visits (assessments can be done by a nurse):
- Assessment of withdrawal symptoms or evidence of functional impairment
- Confirmation of woman’s adherence with counseling recommendations
- Confirmation of woman’s adherence with community-based nursing (parenting) plans
- Confirmation of woman’s adherence to obstetric care (monthly visits until 28 weeks; visits every 2 weeks from 28-36 weeks; weekly visits from 36 weeks to due date at 40 weeks)
- For office-based treatment: Assessment and planning for difficulty with adherence to the treatment plan (i.e., prenatal care, counseling, connection with ancillary services) should be made with each weekly
- For patients with repeated lack of treatment adherence: Reassess whether the woman should remain in an office-based buprenorphine treatment program
- Urine drug screen
- Provide prescription
Between 24-32 Weeks
Establish referrals by directly referring the patient OR by making a specific request to the obstetric provider that he/she make the referral.
- Pediatric provider consultation for evaluation and treatment of neonatal abstinence syndrome (NAS), specifically emphasizing the ability to receive all care at the hospital planned for delivery.
- Anesthesia consultation for pain management plan (reasonable for all women; most important for those planning cesarean delivery).
36-40 Weeks: Delivery and Postpartum Planning
- As the delivery date nears, update the obstetric provider with the appropriate dose of medication
- Remind the obstetric provider that NALBUPHINE (Nubain) and BUTORPHANOL (formally Stadol), and PENTAZCINE (Talwin) are CONTRAINDICATED because they can precipitate acute withdrawal
- Care Coordination for Children (CC4C) referral for ancillary social services
- Encourage breastfeeding
- Refer to home visiting program for mothers for parenting skills and support
- Refer woman’s partner to substance-use disorder treatment, if warranted
Labor, Delivery, and Postpartum
- During labor and delivery, as well as the postpartum process, reassure the woman that providing her with adequate pain control is important; discuss your pain control plan with the woman to reassure her and reduce anxiety.
- Your conversations with obstetric and anesthesia providers should reflect that when a stable patient is requesting pain medication in an appropriate clinical setting, there is no reason to suspect such requests are drug-seeking behaviors.
- Hospital pediatrics should be notified that an opioid exposed neonate will be delivered soon.
- A referral can be made to hospital-based social work to evaluate any needs of the patient postpartum.
- Continue scheduled methadone or buprenorphine during labor and delivery The obstetric provider can order these medications in the hospital even if he or she is not a buprenorphine prescriber, but will not be able to prescribe this medication after the woman’s hospital discharge.
- An anesthesia consult should be made when the patient arrives in labor, as indicated.
- Neuraxial analgesia (spinal, epidural) is effective for pain control during labor or for cesarean delivery for women who are opioid
- Intravenous short-acting NALBUPHINE (Nubain) and BUTORPHANOL (formally Stadol) and PENTAZCINE (Talwin) are CONTRAINDICATED because as they can precipitate withdrawal.
- If any of these drugs is administered mistakenly, and the patient has withdrawal symptoms, an opioid-agonist should be administered to alleviate withdrawal symptoms, and the patient should be closely monitored for respiratory depression.
After the delivery, continue medication-assisted therapy, as indicated, and request the hospital-based social worker assess the patient’s needs.
The methadone or buprenorphine for treatment of the opioid-use disorder will not treat acute pain associated with childbirth.
- For pain control for mild and moderate pain, acetaminophen and non-steroidal anti-inflammatory (NSAID) agents should be used with short-acting opioid analgesics as needed. In a vaginal birth, short-acting opioids can be made available on a PRN basis, just as for non-opioid dependent women.
- For a routine delivery, opioids for pain control should not be needed following hospital
- In the case of a cesarean delivery, continuous short-acting analgesics for 48 hours patient controlled analgesia with intravenous morphine or hydromorphone can be used the first 24 hours. Oral opioids can also be used.
Adequate pain control in women with opioid-use disorders may require up to a 70% increase in short-acting opioid analgesics. Often, a more potent oral agent (i.e., hydromorphone) is required for pain control following a cesarean delivery. If available, consider using individual controlled epidural analgesia, as this approach is effective for severe pain. Expect that short-acting opioids will be needed in decreasing amounts for 5-7 days following cesarean delivery.
