Objective: To provide health care providers the best evidence on opioid use and women's health. Areas of focus include pregnancy and postpartum care. Target population: The target population includes all women currently using or contemplating using opioids. Outcomes: Open, evidence-informed dialogue about opioid use will improve patient care. Benefits, harms, and costs: Exploring opioid use through a trauma-informed approach provides the health care provider and patient with an opportunity to build a strong, collaborative, and therapeutic alliance. This alliance empowers women to make informed choices about their own care. It also allows for the diagnosis and possible treatment of opioid use disorders. Opioid use should not be stigmatized, as stigma leads to poor “partnered care” (i.e., the partnership between the patient and care provider). Health care providers need to understand the effect opioids can have on pregnant women and support them to make knowledgeable decisions about their health. Evidence: A literature search was designed and carried out in PubMed and the Cochrane Library databases from August 2018 until March 2023 using following MeSH terms and keywords (and variants): opioids, opioid agonist therapy, illicit drugs, fertility, pregnancy, fetal development, neonatal abstinence syndrome, and breastfeeding. Validation methods: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). Intended audience: All health care providers who care for pregnant and/or post-partum women and their newborns. Tweetable abstract: Opioid use during pregnancy often co-occurs with mental health issues and is associated with adverse maternal, fetal, and neonatal outcomes; treatment of opioid use disorder with agonist therapy for pregnant women can be safe during pregnancy where the risks outnumber the benefits. SUMMARY STATEMENTS: 1. Opioids are highly addictive and often prescribed for pain relief and overprescribing has contributed to the opioid epidemic in Canada (high). 2. Opioids should only be prescribed when absolutely necessary, in the lowest effective dose, and for the shortest duration necessary (high). 3. Pregnant women who use illicit opioids are at increased risk of sexually transmitted infections, being victims of and/or participating in violence and other illegal activity, concurrent mental health disorders, polysubstance use, poor nutrition, and reliance on social assistance (moderate). 4. During pregnancy, a woman's physiological changes can affect the pharmacokinetic properties of exogenous opioids (moderate). 5. Prenatal opioid exposure has been associated with preterm birth, an infant small for gestational age, and decreased fetal heart rate, although more data are needed (low/moderate); prenatal opioid exposure can cause neonatal opioid withdrawal (high). 6. Women undergoing opioid agonist therapy may require higher doses of short-acting opioids for analgesia and, in some cases, high-affinity opioids for intrapartum and postpartum pain management (high). 7. Opioids can be safely used for pain control in labour for women on opioid agonist therapy; however, higher doses may be required in these women compared to women who are opioid-naive (moderate). 8. Use of opioid antagonists (naltrexone and naloxone) for pregnant women with opioid use disorder remains understudied, and there are gaps in knowledge concerning the safety and efficacy for use during pregnancy (very low). 9. To help pregnant women transition from injectable opioid agonist therapy or illicit opioid use to oral opioid agonist therapy in the antepartum period, methadone or slow-release oral morphine may be preferable to buprenorphine/naloxone, as these options do not require a period of opioid abstinence before beginning therapy (moderate). RECOMMENDATIONS: 1. Health care providers should only prescribe opioids when other evidence-based medical and psychosocial therapies have failed (strong, high). 2. When interpreting antepartum and intrapartum non-stress tests and fetal heart surveillance, health care providers should consider the suppression of fetal heart rate due to opioids and reduced variability and accelerations in fetal heart rate at the opioid's biological peak (strong, moderate). 3. Health care providers should recommend against using non-prescribed opioids, illicit opioids, or other non-prescribed substances while breastfeeding (strong, moderate), but women receiving stable doses of opioid agonist therapy or opioids for chronic pain should be supported to breastfeed (strong, moderate). 4. Health care providers must have a conversation with their pregnant patients concerning the risks and benefits of prescribed opioids for chronic pain, to weigh the likelihood of increased pain when reducing or stopping medication against potential adverse effects on the pregnancy from continuing therapeutic doses of pain medication (strong, high). 5. Health care providers should titrate opioid treatment for chronic, non-cancer pain management in pregnant women to the lowest effective dose, with the understanding that the dose may need to be increased because of the metabolic changes caused by pregnancy (strong, high). 6. Delivery should take place in a centre that can provide monitoring for neonatal withdrawal and infants exposed to opiates during pregnancy should be observed carefully during the neonatal period(strong, high). 7. Health care providers should offer nicotine replacement therapy to pregnant patients with concurrent nicotine and opioid use, in conjunction with a discussion of risks and benefits, in settings where access to tobacco or cigarettes is limited (i.e. in hospital during the intrapartum and postpartum periods) as a way to reduce pain sensitivity (strong, low). 8. Health care providers should recommend epidural analgesia early in labour for women with opioid use disorder, as this may mitigate the hyperalgesia caused by chronic opioid use (strong, moderate). 9. Health care providers should conduct universal screening for substance use and opioid use disorder in pregnant patients, with their consent, using evidence-based screening tools (strong, moderate). 10. Pregnant patients with opioid use disorder should be referred to integrated care programs, when these are available and accessible (strong, moderate). 11. Obstetrical care providers should not attempt to taper the opioid dose or to detoxify (taper completely) in women with opioid use disorder during pregnancy (strong, high). However, following a discussion of the obstetrical and fetal risks of tapering or detoxification, the patient may make an informed decision to undergo this process. In this case, the opioid dose should be slowly tapered to the lowest effective dose (strong, low). 12. Health care providers should recommend treatment with opioid agonist therapy for pregnant women with opioid use disorder, initiating treatment at the lowest effective dose and increase the dose as the pregnancy progresses because of the physiological and metabolic changes associated with pregnancy (strong, high). 13. Obstetrical care providers should consider dose increases and split doses of methadone or buprenorphine for opioid use disorder to prevent withdrawal and relapse during pregnancy because of the increase in metabolism of opioids as pregnancy progresses (strong, high). 14. Women receiving stable doses of opioid agonist therapy may need their dose increased as the pregnancy progresses because of the physiological and metabolic changes during pregnancy (strong, high). 15. Health care providers can safely recommend buprenorphine/naloxone in pregnancy based on current data. Consequently, switching patients to a buprenorphine-only product is not necessary (strong, high). 16. Health care providers should screen pregnant women with opioid use disorder or a history of intravenous drug use for hepatitis C, hepatitis B, syphilis, and HIV (strong, moderate). They should also consider collecting (or having the patient collect) vaginal swabs to test for chlamydia and gonorrhea (strong, moderate). 17. For women with ongoing risk factors for hepatitis B, health care providers should offer hepatitis B vaccine on an accelerated schedule to pregnant women who are not immune to hepatitis B infection (strong, high). 18. Although there is a paucity of research on naloxone rescue medication in pregnancy, naloxone should be administered by any trained bystander or medical professional for resuscitation if opioid overdose is suspected in a pregnant patient, as preventing the mother's death from opioid overdose is the top priority (strong, low). © 2023
