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Best practice №13

Ensure methadone and buprenorphine doses are not tapered in the immediate postpartum period

treatment

by Mark Zakowski, Scott Haga, Tipu V. Khan

Last updated September 3rd, 2020

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Overview

Implement an inpatient postpartum protocol to ensure that patients on medication assisted treatment (MAT) have a plan for continued treatment in the postpartum period. 

Why we are recommending this best practice

Women whose opioid maintenance therapy is interrupted are at high risk of relapse and overdose during the postpartum period.

Strategies for implementation

  • Train providers on evaluation of opioid withdrawal and over-sedation in women on opioid maintenance therapy. Create opportunities for nurses responsible for caring for pregnant inpatients to learn and ask questions about facility-specific protocols as well as to learn how to use the Clinical Opiate Withdrawal Scale and the Ramsay Sedation Scale in the care of patients taking maintenance buprenorphine and methadone (Please see the Resources section of this Best Practice: Considerations for Administration of Buprenorphine and Methadone).  

  • Provide information to providers on how to educate women with opioid use disorder (OUD) about MAT. Educate providers on the importance of continuation of maintenance medication in the postpartum period and reassure women on this treatment that it will not be interrupted. 

  • Develop a protocol for ensuring regular dosing of maintenance methadone and buprenorphine. Work with nursing, obstetrics, and pain/addiction medicine specialists to create a protocol to ensure regular dosing and to assess for the need for increased or split dosing during the postpartum period. 

  • Methadone: Providers should not decrease the methadone dose in the immediate postpartum period unless it is at the patient’s request and the provider and patient agree using shared decision making or unless over-sedation is observed. Providers can consider increasing or splitting the postpartum methadone dose for better pain control post-cesarean.

  • Buprenorphine: Doses should not be decreased in the immediate postpartum period unless it is at the patient’s request and the provider and patient agree using shared decision-making or if over-sedation is observed.  Providers can consider increasing or splitting the postpartum buprenorphine dose for better pain control post-cesarean.  Consider transitioning buprenorphine-only patients to buprenorphine/naloxone prior to discharge. 

  • Develop a plan for safe outpatient hand-off to a provider who can maintain the patient on MAT. Develop a workflow to ensure pregnant patients with OUD are discharged with a mechanism for uninterrupted continuation of their therapy.  Best practice is to continue MAT in the immediate postpartum period. Tapering or stopping MAT in the acute pain or recovery period may increase maternal morbidity and complications. Warn women that relapse and therefore overdose is common in the postpartum period and close follow-up is necessary.

  • Ensure follow-up with a physician or midwife who is aware of the patient’s OUD and MAT therapy.  Ideally the patient will already know this provider.  This follow-up should be made within 1-2 weeks of discharge.  Postpartum depression should be assessed at this appointment or prior to discharge.  Encourage anti-depressant medication for patients with a positive screen to treat their mood and improve MAT retention.

  • See Resources section below for tools for evaluating patients on chronic opioids for withdrawal.
Kayla

Kayla

Having her baby was one of the most amazing things Kayla had ever experienced. When she held her new baby, she felt like everything was good in the world. Kayla was inspired to take control of her health and her social situation for Baby M. 

The postpartum period is a critical time for the mother and baby. Sudden, disruptive changes in the care plan that do not account for the patient’s preferences and what is presently working may lead to unintended consequences. As a rule, MAT should not be tapered in the postpartum period. Additionally, switching from methadone to buprenorphine is more difficult than the switch from buprenorphine to methadone, and should be done with caution, with full disclosure, at an appropriate time, and with a careful plan in place. 

Resources

References

  • ACOG committee opinion no 711: opioid use and opioid use disorder in pregnancy. Obstet Gynecol. 2017;130: e81-94. doi: 10.1097/AOG.0000000000002235.
  • Schiff DM, Nielsen T, Terplan M, Hood M, Bernson D, Diop H, et al. Fatal and nonfatal overdose among pregnant and postpartum women in Massachusetts. Obstet Gynecol. 2018;132(2): 466-474. doi: 10.1097/AOG.0000000000002734.
  • Caritis SN, Bastian JR, Zhang H. et al. An evidence-based recommendation to increase the dosing frequency of buprenorphine during pregnancy. Am J Obstet Gynecol. 2017;217(4): 459.e1-459.e6. doi: 10.1016/j.ajog.2017.06.029.
  • Jones HE, Johnson RE, O’Grady KE, Jasinski DR, Tuten M, Milio L. Dosing adjustments in postpartum patients maintained on buprenorphine or methadone. J Addict Med. 2008;103-7. doi: 10.1097/ADM.0b013e31815ca2c6.
  • Ellis JD, Cairncross M, Struble CA, Carr MM, Ledgerwood DM, Lundahl LH. Correlates of treatment retention and opioid misuse among postpartum women in methadone treatment. J Addict Med. 2019;13(2):153-158. doi: 10.1097/ADM.0000000000000467.
  • O’Connor AB, Uhler B, O’Brien LM, Knuppel K. Predictors of treatment retention in postpartum women prescribed buprenorphine during pregnancy. J Subst Abuse Treat. 2018;86:26-29. doi: 10.1016/j.jsat.2017.12.001.
  • Krans EE, Bogen D, Richardson G, Park SY, Dunn SL, Day N. Factors associated with buprenorphine versus methadone use in pregnancy. Subst Abus. 2016;37(4):550-557. doi: 10.1080/08897077.2016.1146649.
  • Laslo J, Brunner JM, Burns D, Butler E, Cunningham A, Killpack R, et. al. An overview of available drugs for management of opioid abuse during pregnancy. Matern Health Neonatol Perinatol. 2017;3:4. doi: 10.1186/s40748-017-0044-2.
  • Raymond BL, Kook BT, Richardson MG. The opioid epidemic and pregnancy: implications for anesthetic care. Curr Opin Anaesthesiol. 2018;31(3):243-250. doi: 10.1097/ACO.0000000000000590.
  • Safley RR, Swietlikowski J. Pain management in the opioid-dependent pregnant woman. J Perinat Neonatal Nurs. 2017;31(2):118-125. doi: 10.1097/JPN.0000000000000261.
  • Wilder CM, Winhusen T. Pharmacological management of opioid use disorder in pregnant women. CNS Drugs. 2015;29(8):625-36. doi: 10.1007/s40263-015-0273-8.

Mark Zakowski

MD, FASA

Dr. Mark Zakowski is Chief of Obstetrical Anesthesiology, Fellowship Director and Professor of Anesthesiology at Cedars-Sinai Medical Center in Los Angeles.  He has also served as President of the California Society of Anesthesiologists, the Society for Obstetric Anesthesia and Perinatology, and numerous committees at the state and national level as an advocate for pregnant women and their newborns. Dr. Zakowski has authored many chapters, articles and a book for pregnant women about cesarean sections.

Scott Haga

MPAS, PA-C

Scott Haga is Senior Consultant wiht Health Management Associates and  is a passionate patient advocate with a focus on motivational training, evidence-based treatment, collaboration and tackling the national opioid crisis head-on. He is an experienced medical provider who co-founded and co-led an interdisciplinary complex care intervention for high frequency emergency department utilizers.  He has been recognized as a subject matter expert on addiction, medication assisted treatment for substance use disorders, and building well-functioning interdisciplinary treatment teams.

Tipu V. Khan

MD, FAAFP, FASAM

Dr. Khan is an Addiction Medicine specialist and Chief of Addiction Medicine consult-liaison service and outpatient specialty clinic at Ventura County Medical Center. He is the medical director of Prototypes Southern California which has hundreds of residential treatment beds as well as medical-withdrawal (detox) beds throughout Southern California. Dr. Khan is the Medical Director of the Ventura County Backpack medicine group, and Primary Care Hepatitis C Eradication Project. His niche is managing SUD in pregnancy and is a national speaker on this topic.