Substance Use During Pregnancy and Beyond

Educational Objectives

The goal of this program is to improve management of substance use disorders during pregnancy. After hearing and assimilating this program, the clinician will be better able to:

1. Optimize therapy for opioid use disorder in pregnancy.
2. List opioid agonist therapies compatible with breastfeeding.

Summary

Reproductive justice principles: state that all individuals have reproductive rights, regardless of economic status, race, ethnicity, immigration status, sexual preference, gender identity, or medical conditions, including substance use disorder (SUD); pregnant individuals who use drugs are uniquely vulnerable to involvement with the criminal justice and child welfare systems; Black birthing individuals are twice as likely, Latinos are 20% more likely, and American Indian persons are 6 times more likely to be arrested for drug use during pregnancy; criminalization puts the pregnant person and fetus at risk; prisons and jails still use restraints during labor and delivery, even though this is against the law; restraints are also used during antenatal stays, and breastfeeding is denied

Criminalization of pregnancy outcomes (eg, stillbirth): has increased ≈3-fold since 2006; 9 of 10 cases were related to substance use during pregnancy; 1 in 4 cases involved legal substances; 85% of cases were brought against the medically indigent, highlighting class discrimination; 1 in 3 cases were reported by medical professionals, and 2 in 5 by family regulation workers; Black and poor White individuals were overrepresented; ≈66% were normal pregnancy outcomes; the American College of Obstetricians and Gynecologists argues that punishing individuals for drug use is neither ethical nor effective, as it prevents access to prenatal care; states that have restricted abortion also do not provide a full range of drug-treatment services; Black and American Indian women are particularly harmed by efforts to control reproduction and drug use that draw attention away from underlying issues, eg, poverty, racial discrimination, lack of coherent national health care policy; the harms of illicit drugs are often exaggerated, especially opioids, which are not intrinsically harmful; pregnant individuals avoid prenatal care and drug treatment for fear of arrest and potential child welfare involvement

Relation of reporting requirements to adverse outcomes: in 1974, the Child Abuse Prevention and Treatment Act (CAPTA) established the current child welfare system and defined mandated reporters; it has been amended multiple times; the Plan of Safe Care (PSC) was introduced in 2003 (and reauthorized in 2016) to facilitate help for patients with SUD; while CAPTA and the Central Adoption Resource Authority are federal legislation, states implement their own reporting requirements, eg, mandated reporters, reportable offenses, level of drug exposure during pregnancy that mandates a child welfare report; the latest regulations require all substance-affected newborns to be provided with a PSC, which is shared with a child welfare agency; since 2000, there has been an increase in the number of children <1 yr of age in foster care, with more women being arrested for pregnancy outcomes; the birth parent is at increased risk for relapse, overdose, and maternal mortality; opioid overdose and suicide are the leading causes of perinatal mortality in most states; housing instability, intimate partner violence, initiation of injection drug use, sex work, and repeat substance-exposed pregnancy occur more after family separation (the latter by 3-fold ≤18 mo)

Effects of the foster care system on infants: separation from the mother is considered the first adverse childhood event; heightened autonomic nervous system activity increases the risks for obesity, hypertension, and diabetes mellitus; there is evidence of decreased growth and brain development, as well as insecure disorganized attachment and subsequent mental health problems; other adverse childhood events include higher rates of delinquency, teen pregnancy, economic disadvantage, homelessness, and incarceration

Reporting child abuse: state guidelines for reporting child abuse are often unclear; vague laws are open to misinterpretation and can lead to racial disparities; the California statute does not state that drug use during pregnancy is child abuse; in fact, the results of toxicology alone are not reportable; however, if other risk factors indicate a risk to the child, providers are required to report; Black women with SUD are 10 times more likely to be reported to child welfare; in California, 50% of Black and American Indian families are investigated by child welfare (vs 26% overall)

Screening: overdose mortality increased significantly from 2017 to 2020, driven by fentanyl, and other synthetics and psychostimulants (eg, methamphetamine, cocaine); most overdoses occur 6 to 12 mo postpartum; outcomes can be improved through universal screening tools, providing prenatal care, using evidence-based treatments for SUD, and eliminating stigma and discrimination; validated screening tools include TAPS part 1 (tobacco, alcohol, prescription medication, and other substance use), 4Ps (pregnancy, past, partner, parental use), and SURP-P (Substance-Use-Risk-Profile-Pregnancy); a positive screen should be followed by a specific assessment; patients who continue substance use during pregnancy likely have an SUD and need specialized care; urine toxicology is not useful for screening because it only reports exposure ≤72 hr (except for fentanyl and cannabis, which can be detected for months); confirmatory testing is necessary for positive results, as labetalol can give false-positive results for methamphetamine

Harm-reduction principles: can be used to provide prenatal care; focus on improving nutrition, reducing smoking, alcohol, and drug use, promoting breastfeeding, enhancing dental health, encouraging physical activity, ensuring early and continuous prenatal care, and fostering social and community support

Opioid replacement agonist therapy: during pregnancy offers maternal and fetal benefits; methadone or buprenorphine reduces maternal overdose-related deaths by 70%; buprenorphine reduces all-cause mortality by 50%; treatment reduces the risk for HIV and hepatitis B and C, and increases engagement in prenatal care and recovery treatment; fetuses may still experience neonatal withdrawal, but therapy helps minimize fluctuations in maternal opioid levels, reducing fetal stress, intrauterine fetal death, intrauterine growth restriction, and preterm delivery; both methadone and buprenorphine are safe and effective options

Methadone: is a full opioid agonist; adverse effects include respiratory depression, sedation, and constipation; QT prolongation may occur if the dose exceeds 100 mg daily; understanding pharmacokinetics is important; pregnant women may require 100 to 200 mg, but it takes 3 to 5 days to reach steady state; it is advisable to start with a low dose and gradually increase it; splitting the dose (twice daily) can speed up titration

Buprenorphine: is a partial agonist at the μ opioid receptor; it provides relief from withdrawal symptoms, but the patient does not feel high; a combination with naloxone (eg, Suboxone) is available; naloxone (an opioid receptor antagonist) is added to prevent injection and diversion; buprenorphine alone is available in tablet, patch, and injection forms; films are combination formulations; AEs include constipation, headache, and precipitated withdrawal; health care providers may either start with a low dose and increase gradually or start with a higher dose to saturate the receptors; both methods are safe and effective; the choice of dosing should be patient-centered and individualized; previous buprenorphine-precipitated withdrawal may deter patients from taking it again, but it is preferred because of less severe neonatal withdrawal (split dosing of methadone causes less neonatal withdrawal); neonatal withdrawal is a temporary and treatable condition that can be prevented or ameliorated through rooming-in, breastfeeding, and avoiding other substances, eg, tobacco and selective serotonin reuptake inhibitors (SSRIs; when possible); there is no correlation between opioid agonist therapy dose and duration and severity; it is important to take the appropriate dose, report any withdrawal symptoms, and avoid coprescribing benzodiazepines, gabapentin, and SSRIs (as these can worsen withdrawal)

Breastfeeding: buprenorphine and methadone are compatible with breastfeeding; chestfeeding reduces neonatal withdrawal by 30% and neonatal hospital stays by 50%; it also improves parent-infant bonding and serves as positive reinforcement for parental recovery

Final points: overdose is one of the leading causes of maternal mortality in the United States; it is essential to encourage postpartum individuals to maintain treatment for opioid use disorder and prioritize access to reproductive health services to prevent subsequent exposed pregnancies; SUD is a medical condition and proper prenatal care can help; SUDs are stigmatized conditions, especially in pregnancy; recognize that babies are not born addicted but are physically dependent; focus on person-first language and Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) terminology; stigma and discrimination increase risk for pregnancy complications and maternal mortality

Readings

Graves LE, Turner S, Nader M, et al. Breastfeeding and opiate substitution therapy: Starting to understand infant feeding choices. Subst Abuse: Res Treat. 2016;10s1. doi:10.4137/SART.S34553; Frankeberger J, Jarlenski M, Krans EE, et al. Opioid use disorder and overdose in the first year postpartum: a rapid scoping review and implications for future research. Matern Child Health J. 2023;27(7):1140–1155. doi:10.1007/s10995-023-03614-7; Jarlenski M, Shroff J, Terplan M, et al. Association of race with urine toxicology testing among pregnant patients during labor and delivery. AMA Health Forum. 2023;4(4):e230441. doi:10.1001/jamahealthforum.2023.0441; Simon R, Giroux J, Chor J. Effects of substance use disorder criminalization on American Indian pregnant individuals. AMA J Ethics. 2020;22(10):E862-E867. doi:10.1001/amajethics.2020.862; Suarez EA, Huybrechts KF, Straub L, et al. Buprenorphine versus methadone for opioid use disorder in pregnancy. N Engl J Med.2022;387:2033-2044. doi:10.1056/NEJMoa2203318; Treece JM, Madani MA, Khoury GE, et al. Comprehensive review on methadone‑induced QT prolongation and Torsades. J Pharmacol Pharmacotherapeut. 2018;9:2.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Wright was recorded at the 47th Annual Antepartum and Intrapartum Management, held May 30 to June 1, 2024, in San Francisco, CA, and presented by University of California, San Francisco. For information on upcoming programs from this presenter, please visit Virtualce.ucsf.edu/AIM. Audio Digest thanks the speakers and University of California, San Francisco, for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

OB720102

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.