For those of us who have been through it, when we think of the experience of pregnancy, physical discomfort often comes to mind, including musculoskeletal pain of some kind. From pinched nerves to severe back pain, many pregnant women endure increasing physical hardship as pregnancy progresses, pain that is sometimes compounded by existing chronic pain prior to pregnancy. How do women manage this, and what impact does it have on the growing fetus and newborn? According to current studies, American women are increasingly resorting to prescription painkillers, and the outcome to mother and child are alarming.
The Centers for Disease Control (CDC) recently reported a noticeable rise in the number of prescription opioid-addicted newborns across the U.S. Another study published in April in the New England Journal of Medicine showed a nearly quadruple jump since 2004 in the number of newborns treated for Neonatal Abstinence Syndrome (NAS) or Neonatal Opioid Withdrawal Syndrome (NOWS). These newborns are born dependant on prescription opioid painkillers and must suffer through withdrawal after birth.
What makes this trend different from previous spikes among pregnant women using drugs (often illicit) during pregnancy, is that it spans all socioeconomic levels and regions of the country. And it involves a prescription given to the woman by her primary-care provider.
Washington state’s primary care and pain specialist providers responded quickly to these findings. The result is the May 2015 draft publication Interagency Guidelines on Prescribing Opioids for Pain, designed for primary care physicians for the dosing of prescription opioids, including a section for special populations such as pregnancy, cancer patients and pediatrics.
Alyssa Stephenson-Famy, assistant professor in the Division of Maternal Fetal Medicine and assistant residency program director at the University of Washington School of Medicine, authored the section on pregnancy. She shared her observations for safely prescribing opioid medications for reproductive-age women at a June 2015 discussion with fellow care providers. The discussion was hosted by the Collaborative Opioid Prescribing Education for Risk Evaluation and Mitigating Strategies (COPE-REMS) training program at the University of Washington School of Medicine.
Pain during pregnancy is considered normal
“Pain in pregnancy is ubiquitous, whether back, pelvic or other pain,” Stephenson-Famy says. “Chronic musculoskeletal injury can be made worse by pregnancy, but pain in pregnancy is normal and will get better postpartum.”
So what accounts for the rise in use of opioids among reproductive-age women?
According to two studies published in the last two years (one in Anesthesiology; the other by the CDC) in the last 10–15 years, women ages 15–44 have been asking for prescription pain medication more often, and physicians are also prescribing it more liberally.
Of women on Medicaid, 39 percent have filled a prescription for an opioid, and of women on private insurance, 21 percent have. And 21 percent of women on Medicaid and 14 percent of women with private insurance have high rates of opioid prescription during pregnancy.
Stephenson-Famy’s own observations support this. “Although I don't think I have seen a personal change in my own practice or my prescribing habits, this national data suggests that it is not just marginalized patients that are using opioids during pregnancy, “ she says. “I think this is one of the biggest dangers in assuming this is a problem for only indigent women or those of low socioeconomic status, and turning a blind eye to the more white-collar populations that are less obvious but still using opioids during pregnancy. Any person can be using or abusing opioid medications, so it is best for providers to have a standardized approach to opioid prescriptions, regardless of the type of patient they are caring for.”
Impact on the mother
“A pregnant woman metabolizes [an opioid] differently. If a woman is already on an opioid [when she becomes pregnant], she will have to increase her dose to get the same effect," Stephenson-Famy says. At term, "she will have additional pain with delivery if already on opioids.”
Recent studies show that opioid use during pregnancy can increase a woman’s risk of cardiac arrest, preterm labor, transfusion and cesarean delivery.
Impact on the developing fetus and newborn
Results of the same two studies show opioids cross through the placenta and can result in stillbirth, low birth weight, respiratory conditions, premature birth, and brain, spine and heart defects. Additionally, 30–90 percent of babies exposed require treatment for poor suckling, breathing, irritability and gastrointestinal disturbance.
These are all symptoms of NAS, and a newborn might not develop these symptoms until 14 hours after delivery. This is a particular area of concern, according to Stephenson-Famy: “NAS is showing up post-discharge, and patients may not be telling us. We may be missing these babies.”
It’s not uncommon for a mother to be given an opioid painkiller after giving birth in a hospital. Opioids are effective short-term pain management in postoperative situations such as vaginal or cesarian birth, where the potential for traumatic tissue damage and painful recovery are high. Opioids used immediately following birth in short, physician-managed duration do not harm the mother or the infant, even if the mother begins nursing right away, experts say.
“Before you even talk pain medication, consider the other pain management alternatives, “ Stephenson-Famy says. Physical therapy, exercise, stretches and massage all have reasonable evidence to support reducing chronic pain safely in pregnant women.
Both provider and patient must recognize the risk of prescription narcotics for women of reproductive age, whether or not the patient intends to start a family. As nearly half of pregnancies in the U.S. are unplanned, it is more critical than ever that a woman and her physician thoughtfully manage her prescription drug use. Just as a woman must not take Accutane or warfarin during pregnancy, so too should opioids be avoided. Additionally the stigma of opioid dependence must lesson. Open dialogue between the patient and her provider about pain, non-drug therapies, possible narcotic dependency and associated treatments, minimizes the judgement that might lead a patient to conceal drug use from her physician. Ultimately, experts say, the long-term health of mother and child is at stake.