Why we are recommending this best practice
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 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 opioid replacement therapy. 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.
- Ramsay Sedation Scale: Designed for use in critically ill adults that has broad applicability in evaluation of the range between agitation and over sedation in response to sedatives and analgesics.
- COWS: A clinical opioid withdrawal scale designed to monitor signs of opioid withdrawal.
- Sample Inpatient Medication-Assisted Treatment Induction Algorithms.
- Sample Outpatient Buprenorphine Induction Algorithm.
- Considerations for Administration of Buprenorphine and Methadone.
- Considerations for Treatment of Opioid Use Disorder in Pregnancy.
- Sample Evaluation of Opioid Use Disorder (OUD) in Pregnancy Checklist.
- ACOG Committee Opinion No 711: Opioid Use and Opioid Use Disorder in Pregnancy. Obstet Gynecol. 2017;130: e81-94.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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;10;3:4.
- Raymond BL1, Kook BT, Richardson MG. The opioid epidemic and pregnancy: implications for anesthetic care. Curr Opin Anaesthesiol. 2018;31(3):243-250.
- Safley RR, Swietlikowski J. Pain Management in the Opioid-Dependent Pregnant Woman. J Perinat Neonatal Nurs. 2017;31(2):118-125.
- Wilder CM, Winhusen T. Pharmacological Management of Opioid Use Disorder in Pregnant Women. CNS Drugs. 2015;29(8):625-36.