Consensus Statement on Pain Management for Pregnant Patients with Opioid-Use Disorder from the Society for Obstetric Anesthesia and Perinatology, Society for Maternal-Fetal Medicine, and American Society of Regional Anesthesia and Pain Medicine

Pain management in pregnant patients with opioid use disorder

J. Hopkins, MD

Addiction medicine

Learning objectives

• Brief review of peripartum pain
• Identify unique characteristics of pregnant patients with opioid use disorder
• Review new guidelines on pain management in pregnant patients with OUD, and identify effective/evidence based treatment modalities
• Reflect on areas where evidence is lacking

Research question

• Overall low quality of evidence, limited data on best practices for pain management in patients with OUD
• Limited protocols, evidence-based recommendations in pregnant patients with OUD

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“Provide evidence-based recommendations to optimize pain management while reducing risks and complications associated with OUD in the peripartum period”

Design

Methods

1. Systematic scoping review 2022
2. A working group of subject matter experts identified key questions that would be important and clinically relevant for peripartum pain management in pregnant people with OUD
3. Three smaller work-groups were formed to generate clinical recommendations based on available data in the realms of prenatal optimization, labor analgesia, and post-delivery analgesia
4. Each question was addressed using structured answers, and The American College of Cardiology (ACC) and American Heart Association (AHA) Clinical Practice Guideline Recommendation Classification Systems were used to objectively evaluate each of the element’s level of evidence

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Levels of evidence

A note on pain

• Both pain and addiction involve biopsychosocial aspects
• Those with OUD experience pain differently, both physiologically and systemically

• Patients are worried their pain will not be treated adequately (often true)
• Physicians worried they will worsen or exacerbate OUD
• Increased morbidity and mortality in pregnant patients with OUD
• Limited protocols for standardized care of acute pain in patients with OUD, even more limited for pregnant patients
• There are things already in use that can be more widely adapted, e.g. ERAS protocols

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Prenatal optimization

Big points:

• Many co-morbid conditions in pregnant patients with OUD: smoking, anxiety, depression
• Associated with increased post-operative pain and analgesic requirements
• OUD itself associated with higher pain and increased analgesic requirements in the peripartum period

Prenatal planning, coordination

• Review current/outpatient OUD treatment plan, confirm doses
• Coordinate with outpatient providers if possible
• Early consultation/coordination with other necessary specialties (OB/MFM, anesthesia, addiction, pain, SW, CPS…)
• Coordinate with patient - have they had positive or negative experiences in the past? What has worked, what hasn’t? What are their fears?
• Come up with a trauma-informed plan
• Have a plan for follow-up, pain plan (e.g. ?take home opioids)
• Patient education - ensure patient fully informed

Specific clinical recommendations

Anesthesia consultation

• Should all pregnant people with OUD have a predelivery anesthesiology consult? What should be evaluated and discussed in the anesthesia consult?
• Antenatal anesthesia consultation is recommended for the following goals:
• Coordinate care with other health professionals for pain management
• Establish a trusting relationship in nonjudgmental environment
• Address fears, concerns, and goals regarding opioid analgesia
• Establish a clear pain management plan

Class I, Level C-EO

Methadone

• During pregnancy and in anticipation of labor and delivery, should the methadone dose be split, continued, increased, reduced, or stopped?
• Methadone should be continued in the peridelivery period
• Higher or more frequent dosing may be needed as pregnancy progresses, particularly in the third trimester
• Dividing the total daily dose over shorter dosing intervals (6–8 h) may maximize analgesic benefits in the third trimester
• Rapid methadone titration is not possible
• Use additional short acting opioids as needed

Class I, Level B-NR

Buprenorphine

• During pregnancy and in anticipation of labor and delivery, should the buprenorphine dose be split, continued, increased, reduced, or stopped?
• Buprenorphine should be continued in the peri-delivery period - Class I, Level B-R
• Higher or more frequent dosing may be needed as pregnancy progresses, particularly in the third trimester - Class I, Level C-EO
• Splitting the daily dose to every 6–8 h may potentially improve withdrawal symptoms, in addition to optimizing analgesic benefits - Class IIa, Level C-EO

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Naltrexone

• During pregnancy and in anticipation of labor and delivery, should the naltrexone dose be split, continued, increased, reduced, or stopped?
• ? Switch from NTX to something else if time, weighing risk vs benefit of MOUD changes with patient
• Stop oral naltrexone at least 72 h before labor and delivery or cesarean delivery - Class IIa, Level B-NR
• Naltrexone depot formulations last almost 6 wk, and therefore it may not be feasible to stop naltrexone treatment before planned delivery
• Use a combination of neuraxial and regional anesthesia techniques and nonopioid analgesics to achieve adequate peridelivery pain control - Class IIb, Level C-EO

Complementary/alternative therapies

• What is the role for psychotherapeutic or behavioral interventions (eg, CBT, music therapy, water immersion) or complementary and alternative therapies to address peripartum pain?
• Pain is a very personal experience with biopsychosocial aspects, and need to individualize approach
• Very limited available evidence for acupuncture, aromatherapy for post-cesarean pain, no available evidence for music therapy, CBT, others…
• Given co-occurring psychiatric conditions, CBT and supportive psychotherapy recommended for patients with anxiety disorders in general postpartum patients and for patients with OUD
• Equitable access to anything patients without OUD would have (caution using anything sedating if active use)

Class IIb, Level C-EO

Withdrawal

• Don’t reduce dose of methadone/buprenorphine
• Monitor for withdrawal
• Treat withdrawal with standard therapies
• Clonidine, gabapentin, quetiapine, diphenhydramine/hydroxyzine, acetaminophen, loperamide…

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• Have a plan for patients who arrive to deliver that are not yet on MOUD…
• Might need to use full agonist opioids for withdrawal symptoms (and pain)
• Low-dose buprenorphine induction can occur at same time vs methadone

Labor analgesia

-Patients with OUD (treated or untreated), may have increased and different pain qualities

-Minimize potential implicit bias & suboptimal pain management, use standard practice treating breakthrough labor pain

-Escalate pain management as you would for those without OUD

-Multimodal approach

-Early neuraxial

-Do not necessarily need to avoid opioids - individualize, but anticipate higher required doses of opioids

-Continue MOUD

- Methadone, buprenorphine

Opioid dosing

• Monitor pain frequently
• Equitable use of opioids
• Anticipate higher required doses (?how much…1.5-2x is common)
• Ineffective pain management, missed doses of MOUD leads to disengagement in care
• Staff education

Neuraxial

• Recommended early neuraxial analgesia - Class I, Level B-NR
• Is there any evidence that the response to neuraxial opioids may be altered (less effective) with buprenorphine use? Should opioids in the epidural solution be increased, decreased, or omitted?
• Initiate standard dosing, medications - Class I, Level C-EO
• Do not routinely omit opioids from epidural solution
• Shared decision making should be used regarding removal of neuraxial opioids, as epidural opioid exposure may have implications for postpartum care in some cases (e.g. UDS after discharge)

Neuraxial nonopioid adjuvants

• Should nonopioid adjuvants be added to the epidural solution?
• Nonopioid neuraxial adjuncts may be used when pregnant people desire strict opioid avoidance or the neuraxial opioid is not enough
• Limited evidence to support or refute routinely using nonopioid neuraxial adjuvants including clonidine, epinephrine, dexmedetomidine, or neostigmine

Other options…

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• N2O - use in laboring people with OUD should follow similar indications as patients without OUD – not always practical if ongoing non-prescribed opioid use
• Opioid PCA - no data on this in pregnant patients with OUD. Individualize decision to make sure in line with recovery goals - Class IIa, Level C-EO
• Sufentanil
• Neuraxial labor analgesia is preferred over opioid IV PCA - Class I, Level C-EO

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• Ketamine - Limited fetal-neonatal and lactation safety data
• Lidocaine patches
• Ball exercises, warm water baths, NSAIDs, acupuncture, aromatherapy, music…

Post-delivery analgesia

• Big picture…
• Continue MOUD…consider splitting doses
• Continue multimodal treatment
• NSAIDs and APAP can be opioid sparing - schedule and uncouple from opioids
• Consider extending neuraxial analgesia

Post-CS pain

• What is the role for continuing neuraxial analgesia into the postpartum period?
• Epidural analgesia may be considered to continue 12 to 48 hours after cesarean delivery in patients with OUD (Class IIa, Level C-EO)
• Differs from goals of ERAC - individualize!
• If abdominal wall blocks were not performed, it may be reasonable to continue epidural local anesthetics for patients with OUD after cesarean delivery (Class IIb, Level C-EO)

Regional anesthesia

• What is the role for regional anesthesia? Are any of these options more effective than others?
• Abdominal wall blocks such as TAP (transversus abdominus plane), ESP (erector spinae plane), QLB (quadratus lumborum block), and CWI (continuous wound infiltration) offer analgesia and opioid-sparing benefits
• Most data available for TAP blocks, followed by QLB
• Recommended routine use after CS under GA without neuraxial or otherwise without epidural - Class IIb, Level C-EO

Post-delivery MOUD

• Are changes to MOUD required to enhance analgesia after cesarean delivery?
• Continue MOUD
• Continue methadone dose, fractionate - Class I, Level B-NR
• Buprenorphine has ceiling effect in regards to pain, but consider splitting dose - Level C-LD
• Doses of MOUD may need to be reduced post-partum due to changes in weight/Vd and drug metabolism – ?? when to adjust
• Need serial exams, individualize adjustments in MOUD, taper plan if on additional opioids…Class I, Level B-R

Post-delivery adjuvants

• What is the role of other oral or systemic adjuvants for postcesarean analgesia?
• Ketamine?
• Low level evidence, though can consider as single bolus or infusion
• Dose usually in the range of 0.15 - 0.3mg/kg/h
• Limited data on breastfeeding and infant safety, though likely okay for short periods of time - Class IIb, Level C-LD
• Gabapentin?
• Very conflicting data…
• Studies showing benefit in post-CS pain scores excluded those with OUD
• Contradicting studies on whether gabapentinoids reduce opioid requirements
• Limited data on neonatal side effects
• Current recommendation: routine use not recommended - Class III, Level C-EO

Outpatient plan

• Is there a role for the routine use of oral or parenteral opioids in the hospital or at discharge? Are there special considerations regarding the type, dose, and quantity?
• Rarely after vaginal delivery, though individualize
• Post-CS, anticipate higher doses may be required
• For breastfeeding patients, consider neonatal monitoring for sedation (esp if >40mg oxycodone or equivalent/24 hours…limited data)
• Coordinate with outpatient MOUD providers, or assist with follow-up plan
• Bridge prescription
• Naloxone
• Harm reduction - fentanyl test strips, education

Post-operative complications

• Post-operative pruritis
• Avoid partial agonists which are often used (e.g. nalbuphine or butorphanol)
• Consider 5-HT3 receptor antagonists (e.g. Zofran)
• Unexpected positive UDS
• Critical patients are aware of what medications they are receiving
• Undisclosed exposure to opioids during L&D can have many negative downstream effects…legal, CPS, outpatient OUD treatment…
• Vulnerable time for return to use, overdose…

Conclusions

• First consensus statement on perinatal pain management in OUD
• A lot of room for research given gaps in available evidence, reliance on expert opinion
• Early evaluation/coordination, planning, intervention is paramount - addiction medicine, obstetrics, anesthesia, pain, outpatient team, social work
• A standardized approach, including order sets can be helpful, but pregnant patients with OUD will require individualized planning, frequent reassessments
• May need to take different approach for patients with established OUD treatment plans vs those that do not e.g. ongoing non-prescribed substance use, and those with non-obstetrical painful conditions

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References

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