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    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 euphoria2, 3
    • Side effects can include sedation, respiratory depression and decreased gastrointestinal function2, 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 hepatitis7, 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 continues6, 7
    • Women who are on medical maintenance for opioid use should receive adequate analgesia during labor and delivery6, 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
     
    Resources
    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: http://www.drugabuse.gov/nmassist/?q=nida_questionnaire
    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.
     
     
    January, 2014