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Opioid maintenance therapy is the current standard of care for pregnant women who present with addiction to heroin or opioids. Often providers are uneasy about caring for these patients and prefer to refer them to specialty care. A review of the evidence describes a clear pathway for providers. It is the ethical obligation of providers to screen, assess, and provide concise interventions and referral for specialized therapy for these patients.1 The provider should remain open and nonjudgmental, as often these patients fear shame or disgrace and will delay seeking prenatal care. If the provider follows the interdisciplinary team approach with obstetrics, pediatrics, and pain management as suggested by the evidence, effective management can be applied to these patients.
For millennia, people have been abusing and misusing psychoactive substances, beginning with opium in ancient Mesopotamia. From the opium dens of China in the 17th century to the socially accepted use of morphine in America during the Civil War, addiction and tolerance has been described throughout history. In 1897, Bayer Pharmaceuticals developed an over-the-counter cough suppressant and an alleged cure for morphine addiction called heroin. Eventually it was shown that heroin was not a cure for morphine addiction, and was even more habit forming.2 By 1910 the most popular illicit drug in the United States was heroin. This trend has continued to grow despite multiple attempts by governments worldwide to control opioid manufacturing and expenditure. Heroin use has remained stable in the United States, with approximately 1.2 million users; more recently, 5.2 million users reported abusing prescription opioids.2 During the past decade, a growing number of pregnant women have been abusing and misusing prescription opioids. When these women present for prenatal care, it is vital for health care providers to be confident in the management of these patients. A review of the evidence for treatment will help formulate an appropriate plan of care.
A 24-year-old woman who is G3P2002 presents to the office for prenatal care. She is already 22 weeks pregnant and has not yet received any prenatal care. She states that she had difficulty obtaining insurance to cover prenatal care. A detailed patient history reveals that she has been taking percocet several times a day for a back injury. The details of how she acquired the back injury are unclear, but she was in a motor vehicle accident 11 months ago and has been taking the medication daily since the accident. This scenario is common for patients who present to obstetrics and gynecology offices or triage. In 2012, the American College of Obstetricians and Gynecologists Committee Review examined a study that detected opiates in a screening of pregnant women at a rate of 2.6%.3 Detected opiates can occur as a result of ingestion of opiate-containing pain medications or heroin (Table 1).
TABLE 1. Types of opioids and morphine derivatives
|Substance name||Commercial names||How administered|
|Heroin||Diacetylmorphine||Injected, smoked, snorted|
|Opium||Laudanum, paregoric||Swallowed, smoked|
|Codeine||Empirin, Fiorinal, Tylenol with codeine||Injected, swallowed|
|Morphine||Roxanol, Duramorph||Injected, swallowed, smoked|
|Methadone||Methadose, Dolophine||Swallowed, injected|
|Fentanyl and analogs||Actiq, Duragesic, Sublimaze||Injected, smoked, snorted|
|Oxycodone hydrochloride||Tylox, Oxycontin, Percodan, Percocet||Chewed, swallowed, snorted, injected, suppositories|
|Hydrocodone bitartrate, Hydromorphone||Vicodin, Lortab, Lorcet, Dilaudid|
|Oxymorphone||Opana, Numorphan, Numorphone|