Substance use disorders (SUDs) have been a long-standing international problem and recently, use of opioid drugs in the United States has increased to epidemic proportions (U.S. Department of Health and Human Services [USDHHS] Office on Women's Health [OWH], 2016). Opioid use disorders (OUDs) affect all socioeconomic groups, races, ethnicities, and regions, including individuals who are or may become pregnant. Because opioid drugs are transmitted to the fetus through the placenta, neonates exposed to opioid drugs in utero can have withdrawal symptoms or neonatal abstinence syndrome (NAS). In neonates with NAS, tapering doses of oral morphine or methadone is recommended after birth to wean them off opioid drugs (Hudak & Tan, 2012; McQueen & Murphy-Oikonen, 2016). Factors that prohibit women from seeking help for OUDs in pregnancy include stigmatization and fear of punitive repercussions. Health care professionals can address this crisis through decreased stigma toward women with OUDs in pregnancy, universal substance use screening, facilitation of medication assisted treatment (MAT), mental health disorder screening, breastfeeding education, and encouragement of contraceptive use, as well as by advocating for nonpunitive public health initiatives for women with OUDs in pregnancy (McQueen & Murphy-Oikonen, 2016; Worley, 2014).
Scope of the Problem
Opioid Drug Use Crisis
Opioid drug use in the United States has quadrupled over the past decade (Reddy, Davis, Ren, & Greene, 2017). The United States is 4.6% of the world's population yet constitutes 80% of opioid drug consumption (Terplan, 2017). In 2015, an estimated 2 million individuals reported prescription OUD and approximately 600,000 individuals reported heroin OUD (O'Donnell, Halpin, Mattson, Goldberger, & Gladden, 2017). Prescribing of opioid medications has begun to level off and is no longer considered the driver of the opioid drug epidemic due to several factors, including new Centers for Disease Control and Prevention (CDC; 2017) prescribing guidelines, public awareness, databases to track opioid drug prescriptions, and other regulatory measures. Between 2011 and 2015, there has been an increase in heroin use–related deaths, and in 2014, a dramatic increase occurred in synthetic opioid drug use, primarily illicit fentanyl and fentanyl analogs, which are 50 to 100 times more potent than heroin (O'Donnell, Halpin, et al., 2017; Terplan, 2017). Heroin and fentanyl use is now the primary driver of the opioid drug epidemic (Compton, Jones, & Baldwin, 2016; Lind et al., 2017).
Opioid Drug Crisis and Women in Pregnancy
Between 2002 and 2013, heroin use among women increased 100% compared to 50% among men (USDHHS OWH, 2016). In 2015, opioid drug–related overdose took the lives of 31 women per day, and although more men than women die from opioid drug overdose, between 1999 and 2010, women had a 400% increase in deaths compared to a 237% increase in men (Terplan, 2017). Higher death rates between 2006 and 2015 are attributed to increased availability and use of heroin and fentanyl (O'Donnell, Gladden, & Seth, 2017). SUDs can have more severe outcomes in women for reasons that are not fully understood but thought to be due to smaller body size, body metabolism differences, and becoming physically dependent more quickly than men (USDHHS OWH, 2016).
Opioid drugs cross the placental and blood–brain barriers, bind to specific G-protein coupled receptors in the brain, and have physiological effects including altered pain perception and depressed respirations (Baldacchino, Arbuckle, Petrie, & McCowan, 2014; Reddy et al., 2017). Between 1998 and 2011, opioid drug use among pregnant women increased by 127%, which has resulted in obstetric complications including spontaneous abortion, membrane rupture, preeclampsia, and abruption placenta (Lind et al., 2017). The standard of care in obstetrics has been to initiate MAT with methadone, an opioid agonist, or more recently, buprenorphine, a partial opioid agonist (Zedler et al., 2016). Buprenorphine, being a partial opioid agonist, can make overdose less likely, has less drug interactions, and requires less dosage adjustments than methadone (American College of Obstetricians and Gynecologists [ACOG], 2017; Reddy et al., 2017). Buprenorphine can be administered in an office-based setting, increasing adherence and reducing the threat of stigmatization, a concern in the pregnant population (Reddy et al., 2017; Zedler et al., 2016). Pharmacological management maintains stable opioid blood levels, which reduce cravings and relapse and improve fetal and neonate outcomes in comparison with untreated OUD and abrupt opioid drug cessation (Zedler et al., 2016). Relapse rates following medically supervised withdrawal in the general population range from 59% to >90% (ACOG, 2017; Reddy et al., 2017). However, emerging evidence suggests that when MAT is not an option because a woman refuses or treatment is unavailable, medically supervised detoxification, often in the inpatient setting, and with informed consent, combined with behavioral management can be considered (ACOG, 2017; Bell et al., 2016). Medical detoxification during pregnancy is an emerging practice, which may reduce the incidence of NAS after birth, but there are currently no long-term studies on pregnancy in women with OUD or neonates, so presently it is not the standard of care and further research is warranted (Bell et al., 2016).
Neonatal Abstinence Syndrome
According to the ACOG (2017), between 30% and 80% of neonates born after in utero opioid drug exposure will have NAS. Between 2004 and 2013, neonatal intensive care admissions for NAS increased almost threefold; length of hospital stay increased from 13 to 19 days, and 30-day hospital readmissions were twice as likely (Patrick et al., 2015; Tolia et al., 2015). In addition, the cost of providing care to babies born with NAS reached $1.5 billion in 2012 (Devlin, Lau, & Radmacher, 2017).
A neonate with NAS experiences complex and varied symptoms, including gastrointestinal, autonomic, and central nervous system disturbances, leading to high-pitched crying, poor sleep, irritability, tremors, seizures, hypertonia, hyperreflexia, regurgitation, loose stools, tachypnea, feeding difficulties due to uncoordinated sucking reflexes, sweating, sneezing, yawning, nasal stuffiness, and hyperthermia (ACOG, 2017; Reddy et al., 2017). The American Academy of Pediatrics (AAP) recommends neonate observation for 3 to 7 days; however, recent evidence supports observation for 5 days (McQueen & Murphy-Oikonen, 2016). All neonates with NAS require supportive care with a soothing, calm, quiet, minimally lit environment. Care should be clustered to promote rest, including neonate swaddling and holding, and providing time for non-nutritive sucking (McQueen & Murphy-Oikonen, 2016). Consideration of additional interventions include music therapy, massage, and volunteer cuddlers (McQueen & Murphy-Oikonen, 2016). Unless contraindicated, breast-feeding should be encouraged, even when the mother is also being weaned off heroin with an opioid medication or is on MAT, as well as consideration of rooming-in to improve outcomes and enhance neonate–mother bonding (McQueen & Murphy-Oikonen, 2016). In neonates with moderate-to-severe withdrawal symptoms, oral morphine or methadone with preservative-free formulations is recommended (Hudak & Tan, 2012; McQueen & Murphy-Oikonen, 2016).
Barriers to Treatment: Stigma and Fear
Stigma has been identified as a barrier for individuals with SUDs, as they are often labeled as dangerous, immoral, and/or criminal, which results in only approximately 25% seeking care (Corrigan et al., 2017; Kennedy-Hendricks, McGinty, & Barry, 2016). In the case of opioid drug use during pregnancy, women can experience public blame and condemnation, labeled as choosing to harm their fetus, and violating traditional maternal duty (Kennedy-Hendricks et al., 2016). In addition, studies have shown that health care providers, including nurses, hold stigmatizing beliefs toward individuals with SUDs, which result in decreased empathy and engagement with patients (Worley & Delaney, 2017). Given the complexity of OUDs in pregnancy, health care professionals need to remain mindful of associated stigma and provide compassionate care with consistent advocacy for social services and social justice based on a chronic illness framework to guide assessment, intervention, and evaluation (Association of Women's Health, Obstetrics, and Neonatal Nurses [AWHONN], 2015).
In addition to stigma, another barrier for women seeking help for OUDs in pregnancy is that in many cases, women can be criminally charged or face other penalties from using substances in pregnancy. In the United States, 24 states and the District of Columbia (D.C.) consider prenatal substance use child abuse, 23 states and D.C. require health care professionals report suspected substance use, seven states require testing for suspected substance use, and in three states, substance use is grounds for civil commitment (Guttmacher Institute, 2017). In 18 states, substance use while pregnant can be classified as criminal child abuse with the potential for parental right termination (Krans & Patrick, 2016). The Supreme Courts of Alabama and South Carolina consider substance use during pregnancy a crime allowing for prosecution (Miranda, Dixon, & Reyes, 2015). In 2014, Tennessee became the first state to prosecute women for assault for using opioid drugs during pregnancy; however, in 2016 that law was allowed to expire (Hui, Angelotta, & Fisher, 2017). Several states have prosecuted women for substance use during pregnancy, which has resulted in time in prison (Miranda et al., 2015). This punitive-driven system has been proven to reduce maternal self-reporting, reduce use of prenatal care, reduce use of effective MAT options, and ultimately negatively affect the woman, fetus, and neonate (ACOG, 2017; AWHONN, 2015; Wilder, Lewis, & Winhusen, 2015).
The Office of National Drug Control Policy encourages family-based treatment programs and specialized interventions in place of incarceration (USDHHS OWH, 2016). The AAP has continually reaffirmed its position that “punitive measures taken toward pregnant women, such as criminal prosecution and incarceration, have no proven benefits for infant health” (Patrick & Schiff, 2017, p. 3). In addition to the AAP, numerous women's health care and addiction professional organizations have recognized the needs of pregnant opioid drug users and established statements opposing practices that deter screening and treatment, such as the prosecution of women with drug addiction (ACOG, 2017; American Society of Addiction Medicine [ASAM], 2015; AWHONN, 2015; Patrick & Schiff, 2017).
Given the above evidence, The Eunice Kennedy Shriver National Institute of Child Health and Human Development, ACOG, AAP, Society for Maternal-Fetal Medicine, CDC, and the March of Dimes Foundation prepared an executive summary of screening and management guidelines for opioid drug use in pregnancy, NAS, and childhood outcomes (Reddy et al., 2017):
- Universal SUD screening should be initiated at the initial prenatal visit and throughout pregnancy using validated screening tools. The 4Ps (parents' substance use, partner substance use/problematic temper, past depressed mood/decreased pleasure, and present pregnancy/1-month prior substance use) was specifically developed for use in pregnancy (Ewing, 1990). Face-to-face patient encounters have been shown to lead to greater discussion of treatments and resources.
- All women with OUDs should be referred for MAT, which provides withdrawal management, craving reduction, substance use prevention, and reduces fetal harm and stress. In addition to MAT, women should undergo SUD counseling, family therapy, and nutritional education.
- Pregnant women with an OUD have unique needs, and prenatal care should include evaluation of mental health disorders (e.g., mood disorders, anxiety, posttraumatic stress disorder), and a comprehensive history of physical and sexual abuse.
- Peripartum pain management poses a challenge and special considerations for labor-related and postpartum pain management are necessary.
- Breastfeeding is encouraged and associated with decreased severity of NAS, improved maternal confidence, decreased maternal stress, and mother–child bonding. In addition, when compared with formula-fed neonates, breastfed neonates require less pharmacological management for NAS and shorter hospital stays.
- Long-acting reversible contraception insertion before patient discharges should be considered given that more than 80% of pregnancies by women with OUD are unintended.
- Access should be provided to adequate postpartum psychosocial support services, including SUD treatment, substance use prevention programs, and incorporation of postpartum psychiatric screening.
- The mother–caregiver environment should be assessed to promote adequate bonding and NAS monitoring with supportive care, and if required, pharmacological management. Current NAS screening tools are subjective and optimal assessment has not been definitively identified (Reddy et al., 2017).
Pregnant women across all spheres of U.S. society are the face of the opioid drug crisis. Health care professionals should educate women about associated risks of substance use during pregnancy and contraception prevention options. In addition, it is necessary to advocate for policy changes that support treatment and increase prenatal care instead of punitive responses, which have proven ineffective. Many maternal and neonate sequela could be avoided with effective interventions; regrettably, most cases of neonatal exposure are identified after birth. Management of women with OUD in pregnancy include prenatal substance use screening at initial visit and routinely throughout pregnancy. Treatment recommendations include MAT with methadone or buprenorphine as well as identifying and treating other mental health disorders. Women should be with their neonates in a supportive environment to enhance maternal child bonding and breastfeeding, which has been shown to improve NAS outcomes. The opioid drug crisis in pregnancy has profound ramifications and there is a need for evidence-based interventions as well as future research to improve prevention strategies, identification, and management.
- American College of Obstetricians and Gynecologists. (2017). ACOG committee opinion. Retrieved from https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Opioid-Use-and-Opioid-Use-Disorder-in-Pregnancy
- American Society of Addiction Medicine. (2015). The ASAM national practice guideline for the use of medications in the treatment of addiction involving opioid use. Retrieved from https://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement.pdf?sfvrsn=24
- Association of Women's Health Obstetrics and Neonatal Nurses. (2015). Criminalization of pregnant women with substance use disorders. Journal of Obstetric, Gyneco-logic, and Neonatal Nursing, 44, 155–157. doi:10.1111/1552-6909.12531 [CrossRef]
- Baldacchino, A., Arbuckle, K., Petrie, D.J. & McCowan, C. (2014). Neurobehavioral consequences of chronic intrauterine opioid exposure in infants and pre-school children: A systematic review and meta-analysis. BMC Psychiatry, 14, 104. doi:10.1186/1471-244X-14-104 [CrossRef]
- Bell, J., Towers, C.V., Hennessy, M.D., Heitzman, C., Smith, B. & Chattin, K. (2016). Detoxification from opiate drugs during pregnancy. American Journal of Obstetrics and Gynecology, 215, 374.e1–374.e6. doi:10.1016/j.ajog.2016.03.015 [CrossRef]
- Centers for Disease Control and Prevention. (2017). Annual surveillance report of drug-related risks and outcomes – United States, 2017. Retrieved from https://www.cdc.gov/drugoverdose/pdf/pubs/2017-cdc-drug-surveillance-report.pdf
- Compton, W.M., Jones, C.M. & Baldwin, G.T. (2016). Relationship between non-medical prescription-opioid use and heroin use. New England Journal of Medicine, 374, 154–163. doi:. doi:10.1056/NEJMra1508490 [CrossRef]
- Corrigan, P., Schomerus, G., Shuman, V., Kraus, D., Perlick, D., Harnish, A. & Smelson, D. (2017). Developing a research agenda for understanding the stigma of addictions part I: Lessons from the mental health stigma literature. American Journal on Addictions, 26, 59–66. doi:10.1111/ajad.12458 [CrossRef]
- Devlin, L.A., Lau, T. & Radmacher, P.G. (2017). Decreasing total medication exposure and length of stay while completing withdrawal for neonatal abstinence syndrome during the neonatal hospital stay. Frontiers in Pediatrics, 5, 216. doi:10.3389/fped.2017.00216 [CrossRef]
- Ewing, E. (1990). A practical guide to intervention in health and social services, with pregnant and postpartum addicts and alcoholics. Martinez, CA: The Born Free Project, Contra Costa County Department of Health Services.
- Guttmacher Institute. (2017). Substance use during pregnancy. Retrieved from https://www.guttmacher.org/state-policy/explore/substance-use-during-pregnancy
- Hudak, M.L. & Tan, R.C. (2012). Neonatal drug withdrawal. Pediatrics, 129, e540–e560. doi:10.1542/peds.2011-3212 [CrossRef]
- Hui, K., Angelotta, C. & Fisher, C.E. (2017). Criminalizing substance use in pregnancy: Misplaced priorities. Addiction, 112, 1123–1125. doi:10.1111/add.13776 [CrossRef]
- Lind, J.L., Interrante, J.D., Ailes, E.C., Gilboa, S.M., Khan, S., Frey, M.T. & Broussard, C.S. (2017). Maternal use of opioids during pregnancy and congenital malformations: A systematic review. Pediatrics, 139, e20164131. doi:10.1542/peds.2016-4131 [CrossRef]
- Kennedy-Hendricks, A., McGinty, E.E. & Barry, C.L. (2016). Effects of competing narratives on public perceptions of opioid pain reliever addiction during pregnancy. Journal of Health, Politics, Policy & Law, 4, 873–916. doi:10.1215/03616878-3632230 [CrossRef]
- Krans, E.E. & Patrick, S.W. (2016). Opioid use disorder in pregnancy: Health policy and practice in the midst of an epidemic. Obstetrics & Oncology, 128, 4–10. doi:10.1097/AOG.0000000000001446 [CrossRef]
- McQueen, K. & Murphy-Oikonen, J. (2016). Neonatal abstinence syndrome. New England Journal of Medicine, 375, 2468–2479. doi:10.1056/NEJMra1600879 [CrossRef]
- Miranda, L., Dixon, V. & Reyes, C. (2015, September30). How states handle drug use during pregnancy. Retrieved from https://projects.propublica.org/graphics/maternity-drug-policies-by-state
- O'Donnell, J.K., Gladden, R.M. & Seth, P. (2017). Trends in deaths involving heroin and synthetic opioids excluding methadone, and law enforcement drug product reports, by census region—United States, 2006–2015. MMWR Morbidity and Mortality Weekly Report, 66, 897–903. doi:10.15585/mmwr.mm6634a2 [CrossRef]
- O'Donnell, J.K., Halpin, J., Mattson, C.L., Goldberger, B.A. & Gladden, R.M. (2017). Deaths involving fentanyl, fentanyl analogs, and U-47700—10 States, July–December 2016. MMWR Morbidity and Mortality Weekly Report, 66, 1197–1202. doi:10.15585/mmwr.mm6643e1 [CrossRef]
- Patrick, S.S., Burke, J.F., Biel, T.J., Auger, K.A., Goyal, N.K. & Cooper, W.O. (2015). Risk of hospital readmission among infants with neonatal abstinence syndrome. Hospital Pediatrics, 5, 513–519. doi:10.1542/hpeds.2015-0024 [CrossRef]
- Patrick, S.W. & Schiff, D.M. (2017). A public health response to opioid use in pregnancy. Pediatrics, 139, e20164070. doi:. doi:10.1542/peds.2016-4070 [CrossRef]
- Reddy, U., Davis, J.M., Ren, Z. & Greene, M.F. (2017). Opioid use in pregnancy, neonatal abstinence syndrome, and childhood outcomes: Executive summary of a joint workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, American College of Obstetricians and Gynecologists, American Academy of Pediatrics, Society for Maternal-Fetal Medicine, Centers for Disease Control and Prevention, and the March of Dimes Foundation. Obstetrics and Gynecology, 130, 10–28. doi:10.1097/AOG.0000000000002054 [CrossRef]
- Terplan, M. (2017). Women and the opioid crisis: Historical context and public health solutions. Fertility and Sterility, 108, 195–199. doi:10.1016/j.fertnstert.2017.06.007 [CrossRef]
- Tolia, V.N., Patrick, S.W., Bennett, M.M., Murthy, K., Sousa, J., Smith, B. & Spitzer, A.R. (2015). Increasing incidence of the neonatal abstinence syndrome in U.S. neonatal ICUs. New England Journal of Medicine, 372, 2118–2126. doi:10.1056/NEJMsa1500439 [CrossRef]
- U.S. Department of Health and Human Services, Office on Women's Health. (2016). White paper: Opioid use, misuse, and overdose in women. Retrieved from https://www.womenshealth.gov/files/documents/white-paper-opioid-508.pdf
- Wilder, C., Lewis, D. & Winhusen, T. (2015). Medication assisted treatment discontinuation in pregnant and postpartum women with opioid use disorder. Drug and Alcohol Dependence, 149, 225–231. doi:10.1016/j.drugalcdep.2015.02.012 [CrossRef]
- Worley, J. (2014). Identification and management of prescription drug abuse in pregnancy. Journal of Perinatal & Neonatal Nursing, 28, 196–203. doi:10.1097/JPN.0000000000000039 [CrossRef]
- Worley, J. & Delaney, K.R. (2017). “Turning the tide” in treatment of substance use: A nursing response”. Journal of Nursing Education and Practice, 8, 116–124. doi:10.5430/jnep.v8n2p116 [CrossRef]
- Zedler, B.K., Mann, A.L., Kim, M.M., Amick, H.R., Joyce, A.R., Murrelle, E.L. & Jones, H.E. (2016). 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, 111, 2115–2128. doi:10.1111/add.13462 [CrossRef]