Pregnancy, puerperium and substance use

Meet the patient

A 29-year-old, 22 weeks pregnant, is referred from the antenatal clinic after a positive opioid screen. She has been on illicit opioids for two years and missed her last two scans. She is terrified that the baby will be taken at birth. Her partner uses with her.[5][6]

The fellowship task is not to judge her, and it is not to detox her against the evidence. It is to engage her today, start opioid agonist treatment, plan for a treatable neonatal withdrawal syndrome, and keep her in antenatal care through the postpartum year — because the postpartum window is when most people disengage and overdose risk rises. This topic teaches you to do all of that without moral theatre.[3][5][18]

References18Show ledgerHide ledger

1. [1]Jones HE, Kaltenbach K, Heil SH, et al. Neonatal abstinence syndrome after methadone or buprenorphine exposure N Engl J Med, 2010.PMID 21142534
2. [2]Suarez EA, Huybrechts KF, Straub L, et al. Buprenorphine versus Methadone for Opioid Use Disorder in Pregnancy N Engl J Med, 2022.PMID 36449419
3. [3]Minozzi S, Amato L, Jahanfar S, et al. Maintenance agonist treatments for opiate-dependent pregnant women Cochrane Database Syst Rev, 2020.PMID 33165953
4. [4]Zedler BK, Mann AL, Kim MM, et al. Buprenorphine compared with methadone to treat pregnant women with opioid use disorder: a systematic review and meta-analysis of safety in the mother, fetus and child Addiction, 2016.PMID 27223595
5. [5]Klaman SL, Isaacs K, Leopold A, et al. Treating Women Who Are Pregnant and Parenting for Opioid Use Disorder and the Concurrent Care of Their Infants and Children: Literature Review to Support National Guidance J Addict Med, 2017.PMID 28406856
6. [6]American College of Obstetricians and Gynecologists Committee Opinion No. 711 Summary: Opioid Use and Opioid Use Disorder in Pregnancy Obstet Gynecol, 2017.PMID 28742670
7. [7]American Society of Addiction Medicine The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update J Addict Med, 2020.PMID 32511106
8. [8]Popova S, Lange S, Probst C, Gmel G, Rehm J Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysis Lancet Glob Health, 2017.PMID 28089487
9. [9]Behnke M, Smith VC; Committee on Substance Abuse; Committee on Fetus and Newborn Prenatal substance abuse: short- and long-term effects on the exposed fetus Pediatrics, 2013.PMID 23439891
10. [10]Hudak ML, Tan RC; Committee on Drugs; Committee on Fetus and Newborn Neonatal drug withdrawal Pediatrics, 2012.PMID 22291123
11. [11]Forray A Substance use during pregnancy F1000Res, 2016.PMID 27239283
12. [12]Wright TE, Terplan M, Ondersma SJ, et al. The role of screening, brief intervention, and referral to treatment in the perinatal period Am J Obstet Gynecol, 2016.PMID 27373599
13. [13]Coleman T, Chamberlain C, Davey MA, Cooper SE, Leonardi-Bee J Pharmacological interventions for promoting smoking cessation during pregnancy Cochrane Database Syst Rev, 2015.PMID 26690977
14. [14]Tolia VN, Patrick SW, Bennett MM, et al. Increasing incidence of the neonatal abstinence syndrome in U.S. neonatal ICUs N Engl J Med, 2015.PMID 25913111
15. [15]Patrick SW, Davis MM, Lehmann CU, Cooper WO Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012 J Perinatol, 2015.PMID 25927272
16. [16]Terplan M, Smith EJ, Kozloski MJ, Pollack HA Methamphetamine use among pregnant women Obstet Gynecol, 2009.PMID 19461424
17. [17]Kiblawi ZN, Smith LM, Diaz SD, et al. Prenatal methamphetamine exposure and neonatal and infant neurobehavioral outcome: results from the IDEAL study Subst Abus, 2014.PMID 24588296
18. [18]Hirai AH, Ko JY, Owens PL, Stocks C, Patrick SW Neonatal Abstinence Syndrome and Maternal Opioid-Related Diagnoses in the US, 2010-2017 JAMA, 2021.PMID 33433576