​Opioids

What are opioids?

• Opioids include oral opiates like codeine, hydrocodone, oxycodone, fentanyl or meperidine as well as heroin, which can be smoked, used intra-nasally, or injected¹
• Heroin is a synthetic opioid that is lipid soluble and crosses the blood-brain barrier where it is converted to morphine
• Opioids work by binding to three types of opiate receptors throughout the body causing an analgesic effect resulting in increased pain tolerance and feelings of euphoria^{2, 3}
• Side effects can include sedation, respiratory depression and decreased gastrointestinal function^{2, 3}
• Prescription opioids are the most commonly abused prescription drugs in the U.S.⁴
• Heroin is the most commonly used non-prescription opioid in the U.S.²

What are the medical consequences of opioid use?

• Dependence⁴
• Overdose¹
• Respiratory depression⁴
• Sedation⁴
• Liver disease⁵
• Kidney disease⁵
• Pulmonary disease like pneumonia, tuberculosis1
• Chronic constipation⁵
• Withdrawal ^4,5
       Pain¹
       Restlessness¹
       Vomiting¹
       Diarrhea¹
• If injected risks include:
       Increased risk of infection like HIV, HCV⁵        
       Venous problems⁵    

What are the treatment options for opioid abuse?

• There are multiple options for the treatment of opioid dependence in pregnancy including medical detoxification or medical maintenance with methadone or buprenorphine⁶

What are the medical consequences of heroin use in pregnancy?

• Placental abruption⁷
• Preterm labor⁷
• Fetal death⁷
• Decreased birth weight⁸
• Small head circumference
• If heroin is used intravenously, the fetus and the mother are at increased risk of infections like HIV and hepatitis^{7, 9}
• There is some evidence that prenatal exposure to heroin can cause babies to be irritable and difficult to console even in the weeks and months after birth⁸

What are the medical consequences of prescription opioid use in pregnancy?

• Inconsistent data is available regarding some of the fetal effects of prescription opioid use in pregnancy

• Some studies have shown an increased risk of cleft lip and palate, cardiac defects, and gastroschisis with the use of oral opioids¹
• However, other large trials have found no significant increase in risk of congenital malformations with use of opioids in the first trimester

Neonatal Abstinence Syndrome

• Use of both prescription opioids and heroin is clearly associated with neonatal abstinence syndrome when the infant withdraws from opiates after the maternal source is removed¹¹
• It us occurs within 1-10 days of delivery²
• The syndrome affects multiple organ systems including the brain, the GI tract, and the autonomic nervous system¹
• Associated symptoms include:
       Seizures¹²
       Poor feeding¹²
       Vomiting¹²
       Diarrhea¹²  
       Excessive sweating¹²
       Fevers¹²
       Temperature instability¹²

What are the treatment options for opioid abuse in pregnancy?

• There are multiple options for the treatment of opioid dependence in pregnancy including medical detoxification or medical maintenance with methadone or buprenorphinebuprenorphine⁶
• Prior to the introduction of buprenorphine in 2002, the preferred treatment was with methadone as its use was associated with increased compliance and avoidance of repeated intoxication compared to detoxificationbuprenorphine⁶
• Multiple studies have examined the advantages of buprenorphine as compared to methadone6
  While buprenorphine does appear to be associated with less neonatal abstinence syndrome, the two medications seem to be otherwise comparablebuprenorphine⁶
• Due to the changes in pharmacokinetics in pregnancy, the dose of methadone or buprenorphine may need to be increased as pregnancy continues^{6, 7}
• Women who are on medical maintenance for opioid use should receive adequate analgesia during labor and delivery^{6, 7}
• It is important to avoid narcotic agonist-antagonist medications during labor and delivery such as butorphanol, nalbuphine, and pentazocine as they can cause acute opioid withdrawal⁷

1. Heroin: Abuse and Addiction.  Retrieved January 15, 2014 from The National Institute on Drug Abuse Web site: http://www.drugabuse.gov/publications/research-reports/heroin-abuse-addiction
2. Stanhope, T.J. et al (2013).  Chronic opioid use during pregnancy: Maternal and fetal implications. Clin Perinatol 40. 337-350.
3. Lindsay, M.K. and Burnett, E. (2013). The use of narcotic and street drugs during pregnancy. Clinical Obstetrics and Gynecology 56. 133-141.
4. American College of Obstetricians and Gynecologists. (2012).  ACOG Committee Opinion 538: Non-medical Use of Prescription Drugs.  Washington, DC: American College of Obstetricians and Gynecologists.
5. Drug Screen. Retrieved January 15, 2014 from The National Institute on Drug Abuse Web site: https://nida.nih.gov/​​
   
6. Jones, H.E. et al. (2012). Buprenorphine treatment of opioid-dependent pregnant women: a comprehensive review. Addiction 107. 5-27.
7. American College of Obstetricians and Gynecologists. (2012). ACOG Committee Opinion 524: Opioid Abuse, Dependence, and Addiction in Pregnancy. Washington, DC: American College of Obstetricians and Gynecologists.
8. Bandstra, E.S (2010). Prenatal Drug Exposure: Infant and Toddler Outcomes [Electronic Version]. Journal of Addictive Diseases, 29, 245-358.
9.   Kuczkowski, K.M (2007).  The Effects of Drug Abuse on Pregnancy [Electronic Version].  Curr Opin Obstet Gynecol, 19, 578-585.
10. Brenna, M.W. and Rayburn, W.F. (2012). Counseling about risk of congenital anomalies from prescription opioids. Birth Defects Research 94. 620-625.
11. Wendell, A.D (2013). Overview and epidemiology of substance abuse in pregnancy. Clinical Obstetrics and Gynecology 56. 91-96.
12. American Academy of Pediatrics Committee on Drugs (1998). Neonatal Drug Withdrawal [Electronic Version].  Pediatrics, 101:6, 1079-1088.