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Substance use in pregnancy has escalated in recent years. Opioid-dependent patients frequently have severe postoperative pain due to opioid-induced hyperalgesia or tolerance.1 Chronic use of either buprenorphine or methadone can result in these states.
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Currently, due to lack of robust data and guidelines at a national level, healthcare providers have limited options for optimizing the management of this group of patients.
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Coordinated care between obstetrics, anesthesia, addiction medicine, pediatrics, and social work aims to facilitate team collaboration and provide multimodal analgesia in order to provide the best possible postoperative pain control and patient satisfaction, improving maternal and neonatal outcomes.2 This chapter will focus on the role of anesthesiologists in care of parturients with opioid use disorders (OUD) undergoing cesarean delivery. Given the unique needs of pregnant women with OUD, the anesthetic plan will need to be tailored to the patient’s particular situation.
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MEDICATION-ASSISTED TREATMENT (MAT) (TABLE 16-1)
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Pharmacokinetic and physiologic changes in pregnancy may require dose adjustments (usually increase), especially in the third trimester.
The availability of buprenorphine for patients with OUD is the most significant event in addiction medicine since the introduction of methadone maintenance in the 1960s. Buprenorphine is the only opioid agonist currently approved for the treatment of OUD by a prescription in an office-based setting unlike methadone that must be managed in a licensed opioid treatment program.
The human mu opioid receptor occupancy by buprenorphine is dose-related: 27% to 47% at 2 mg and 89% to 98% at 32 mg.3
Naloxone is not orally active. It is used to reduce diversion because Suboxone causes severe withdrawal symptoms when injected.4
Extended-release injectable buprenorphine (Sublocade) is given as a depot injection every 3 months to patients on a stable regiment of buprenorphine of at least 8 mg/day.5
Opiate agonist/antagonist medications such as nalbuphine, butorphanol, and pentazocine are contraindicated as acute withdrawal can be precipitated in the opioid-dependent patient.
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Continue buprenorphine-based or methadone MAT medications at the maintenance dose.
If the patient is receiving methadone, she should not transition to partial agonist such as buprenorphine because of the significant risk of withdrawal.
In patients taking naltrexone, taper to stop 72 hours prior to scheduled cesarean delivery.
The patient should be scheduled for an obstetric anesthesia consult to allow for discussion of the patient’s wishes and to provide reassurance and a plan for postpartum analgesia.