Pregnant Women, Opioid Use Disorder, and Medication-Assisted Treatment
When I write articles, give lectures, or discuss opioid addiction, known as opioid use disorder (OUD), I always remind the people I’m addressing, whether they’re friends, colleagues, or people I’ve never met, this one thing: opioid addiction knows no boundaries. It can affect anyone, from any walk of life. From retired executives to young professionals to high school athletes, everyone is vulnerable. As a fly on the wall in a group therapy session at an addiction treatment center for opioid use disorder, you’d see doctors sitting next to carpenters, lawyers alongside truck drivers, and young adults sharing their addiction stories with people twice their age or more.
That’s what the people behind the opioid crisis statistics look like in the U.S. They look like our population: a diverse mix of people from different culture and backgrounds. They all have a different story to tell. But they all share one thing in common: they need the help that the most effective treatment available for opioid addiction can offer.
When we talk about people with OUD, or people in treatment for OUD, we often forget one segment of the population: pregnant women. A paper published in 2019 called Opioid Use Disorder in Pregnancy details the following potential complications commonly associated with OUD during pregnancy:
· Pre-term labor
· Fetal convulsions
· Fetal distress connected to “daily cycles of maternal opioid use and withdrawal”
· Preterm delivery
· Low birth weight
· Increased risk of birth defects including heart defect, spina bifida, and gastroschisis (a problem in the abdominal wall requiring immediate surgery)
· Neonatal abstinence syndrome (NAS)
Those complications are associated with two things: chronic fetal exposure to opioids and the daily cycles of withdrawal and opioid use that occur during active opioid addiction. However, there’s a way for pregnant women to avoid the bulk of these complications: evidence-based treatment. The best treatment for OUD in pregnant women, as indicated by the American College of Obstetricians and Gynecologists (ACOG) in their publication Opioid Use and Opioid Use Disorder During Pregnancy, is medication-assisted treatment, or MAT.
I’ll talk about MAT and how it helps pregnant women with OUD in a moment. First, I’ll outline the scope of the problem of opioid use during pregnancy, using data from the Centers for Disease Control (CDC).
Opioid Use Disorder During Pregnancy: The Statistics
A CDC report published in 2017 revealed these alarming facts:
· Prevalence of (OUD) during pregnancy more than quadrupled from 1999 to 2014
· Between 2002 and 2009, neonatal abstinence syndrome (NAS) increased five-fold
· In 2009, that meant that one baby was born with NAS every 30 minutes
· By 2018, that increased to one baby born with NAS every 15 minutes
Those statistics weren’t published alongside the early reports on the opioid crisis in the U.S., which detailed the shocking rise in opioid use and overdose deaths between 1999 and 2014. Those rates skyrocketed between 2014 and 2017, abated slightly between 2017 and 2018, and then rose again during the pandemic. Although we don’t have data on OUD and pregnancy for the past two years, I assume rates of OUD mirror the latest overdose statistics, which indicate that in 2020, over 93,000 people died from opioid overdose. That’s 20,000 more than 2019, and the largest single-year increase reported since 1999.
Logic and experience tell me that during the pandemic, there’s been an increase in OUD among pregnant women. That means we need to redouble our efforts to identify and support these women with MAT. And I do mean redouble, literally. A study conducted in Massachusetts shows that before the pandemic related upsurge, between 2011 and 2015, during the first wave of the opioid crisis:
· 38% of pregnant women with OUD consistently used MAT to treat OUD
· 28.1% of pregnant women with OUD inconsistently used MAT to treat OUD
· 33.8% of pregnant women with OUD used no medication at all to treat OUD
Those are the numbers, which make it clear we have a secondary problem embedded within the opioid crisis. The addiction numbers themselves are problematic, but the treatment numbers are even more so, because treatment that can protect both the mother and child from the consequences of OUD during pregnancy is available.
How MAT Helps Pregnant Women and Their Babies
Dr. Maria Mascola of the ACOG, author of the publication cited above, describes the overall benefits of MAT for pregnant women with OUD, and addresses fears often voiced by pregnant women with OUD and their families:
“Concern about medication-assisted treatment must be weighed against the negative effects of ongoing misuse of opioids, which can be much more detrimental to mom and baby. Medication-assisted treatment improves adherence to prenatal care and addiction treatment programs and has been shown to reduce the risk of pregnancy complications.”
I’ll expand on what she means by reduce the risk of pregnancy complications. Properly supervised and managed OUD during pregnancy can:
· Stabilize daily opioid levels and prevent onset of withdrawal symptoms
· Reduces the risk of relapse
· Reduce risk of OUD-related infectious disease
· Increase participation in prenatal care
· Increase participation in addiction treatment
· Improve delivery preparation
· Decrease miscarriage risk
· Decrease preterm labor risk
· Improve birthweight
· Decrease maternal mortality
· Decrease severe OUD-related morbidity (disease/illness)
The most commonly used medications for OUD during pregnancy are methadone and buprenorphine. Of the two, buprenorphine can be prescribed via virtual or telemedicine, while methadone can only be prescribed and distributed during in-person treatment with a licensed physician. Both medications help pregnant women with OUD in all the ways listed above, which can be lifesaving for both the mother and the child.
However, there is one thing I should address: the phenomenon of neonatal abstinence syndrome, or NAS. When a baby is born to a mother with untreated OUD, the sudden absence of opioids causes them to enter withdrawal. The same is true of mothers who are in MAT for OUD: the absence of the opioid agonist triggers NAS.
Here are the facts on NAS and MAT:
· About 50% of women taking methadone or buprenorphine have babies who develop NAS, which means the other 50% have babies who do not develop NAS
· Almost 100% of women with an untreated opioid use disorder have babies who develop NAS
· In comparison to NAS that develops from misused opioids, NAS caused by buprenorphine or methadone is shorter and less severe
I’ll also let Dr. Mascola weigh in on NAS, in an effort to allay the concerns any pregnant woman with OUD may have about entering an MAT program:
“While neonatal abstinence syndrome is often seen in infants who have been exposed prenatally to opioids, it is important to remember that it is an expected and treatable condition that has not been found to have any significant effect on cognitive development.”
For any woman in the complicated position of being pregnant and seeking treatment for OUD, that sentence should have a profound impact: MAT substantially decreases the chance their newborn will suffer complications related to their OUD or treatment for their OUD.
MAT During Pregnancy Creates a Lifetime of Change
There’s another component of the benefits of MAT for pregnant women with OUD I want to elaborate on here. It’s the “T” in MAT. In a MAT program, medication is not the only treatment. In fact, almost all MAT programs require that the person entering treatment participate not only in the medication part of the treatment, but also an integrated addiction treatment program that includes individual therapy, group therapy, addiction education, and community support.
MAT is not a silver bullet. Rather, it’s an essential component of comprehensive approach to addiction treatment. The medication stabilizes a person and allows them to participate fully in treatment and therapy. Stability means both physical and behavioral stability. Physical stability means the absence of cravings and the symptoms of withdrawal, while behavioral stability means a decrease in the negative patterns associated with addiction that impair an individual’s ability to participate fully in work, family, and social life.
For a pregnant woman, stability through MAT means they can take the necessary steps to ensure their overall health, steps which have far-reaching implications for mother and baby alike. Pregnant women in MAT programs are more likely to make all their prenatal doctor visits, follow doctor’s orders during the pre- and perinatal periods, and create a healthy atmosphere for their baby in the post-natal period, i.e. the time immediately following birth.
All those things are a big deal: a pregnant woman with OUD can enter an MAT program and completely change her life and the future life of her child. She can learn the skills she needs to achieve sustainable recovery. She can seek and maintain gainful employment, be present for her child physically and emotionally, and surround herself with a community of recovery counselors and peers that will help her not only on her recovery journey, but also on her transition to motherhood.
I know all this because I’ve seen it happen. When it does, it rekindles my optimistic belief that when we work together and offer the best addiction treatment available to anyone and everyone who needs it, we improve our world, one person at a time. In the case of MAT for pregnant women with OUD, we can improve our world one mom at a time, one brand new baby at a time.
