Opioid Use Disorder __________________________________________________________________________
METHADONE Pregnant women who are opioid dependent should be main- tained on the lowest effective dose of methadone; detoxifica- tion, if attempted, should be done in the second trimester [202]. Inadequate maternal methadone dosage may result in mild-to-moderate opioid withdrawal signs and symptoms that may cause fetal stress and maternal drug cravings, which contributes to relapse and treatment discontinuation [203]. Outcomes are poor for patients who leave treatment. Fetal exposure can result in lower birth weight, smaller head cir- cumference, jaundice, and thrombocytosis, although the cause of these conditions is difficult to distinguish between metha- done and other concurrently used substances. Methadone in the newborn infant will produce physical dependence and subsequent withdrawal symptoms that may not emerge until 48 hours after birth, regardless of maternal dose. Methadone- exposed infants function within a normal range of cognition at one- and two-year evaluations [202]. Methadone levels in breast milk appear to be small [214]. BUPRENORPHINE Buprenorphine has been administered successfully to opioid- dependent pregnant women as a maintenance replacement opioid. Placental transfer may be less than methadone, reducing fetal exposure and subsequent dependence and withdrawal. Buprenorphine has a low incidence of labor and delivery complications and of neonatal abstinence syndrome [202]. Multiple small case series have examined maternal buprenorphine concentrations in breast milk and all concur that the amounts are small and unlikely to have short-term negative effects on the developing infant [215]. Advantages of buprenorphine over methadone include fewer drug interac- tions, the ability to be treated as an outpatient, and evidence of less need for dosage adjustments throughout pregnancy. Additionally, several trials demonstrate evidence of less severe NOWS in affected neonates [203; 216]. OXYCODONE Oxycodone is metabolized to noroxycodone, oxymorphone, and their glucuronides and primarily excreted through urine. Oxycodone has been detected in breast milk, and although not found to be a teratogenic in experimental animals, it is not recommended for use in pregnancy [55]. Management of infants born to mothers abusing oxycodone is of particular concern because the drug and its metabolites are difficult to detect by the enzyme immunoassay methods typically used for urine and meconium opioid screens [217]. NALTREXONE The literature is limited and equivocal regarding naltrexone and pregnancy. Results of a national provider survey reveal that the accessibility of naltrexone and related care for pregnant women with opioid use disorder varies across the United States, with barriers (e.g., providers’ discomfort and inexperi- ence prescribing naltrexone) and educational gaps (e.g., lack of national guidelines) identified [218]. The substantial drop-out rates due to the reward-blocking and dysphoric effects of this
drug have resulted in limited reports on pre- and perinatal complications. One Australian study showed no obstetric complications and healthy-appearing infants, leading the authors to conclude naltrexone is a safe alternative in select pregnant patients [202]. However, other authors have found that naltrexone can cause premature labor and fetal death, and it is considered to be pregnancy category C [8; 55]. The manu- facturer recommends that nursing mothers either discontinue the drug or discontinue nursing [55]. PROGNOSIS OF TREATMENT FOR OPIOID USE DISORDER The relapse rate among patients receiving treatment for opioid dependence and other substance abuse is high (25% to 97%), comparable to that of other patients with chronic relapsing conditions, including hypertension and asthma [219]. Many cases of relapse are attributable to treatment noncompliance and lack of lifestyle modification [87]. Duration of agonist replacement therapy is usually recom- mended as a minimum of one year, and some patients will receive agonist replacement therapy indefinitely. Longer dura- tions of treatment are associated with higher rates of abstinence from illicit opioids [30]. Much remains unknown about patient outcomes following termination of long-term opioid replacement therapy. Some patients aim to achieve total abstinence from all opioids, but little is known about patient characteristics and strategies used among those who remain abstinent. It is likely that at least some of the patients who remain abstinent from all opioids do so with the help of a 12-step support program, such as NA [30]. CONCLUSION Dependence on opioids is associated with serious morbidity and mortality, and advances in the understanding of the dependence have led to the development of effective treat- ments. More recently, the abuse of prescription opioids has become considerably more widespread, fueled in part by the availability of such drugs over the Internet. This has resulted in opioid abuse and dependence in populations seldom afflicted in the past. Thus, medical, mental health, and other healthcare professionals in a variety of settings may encounter patients with an opioid use disorder. The knowledge gained from the contents of this course can greatly assist the healthcare profes- sional in identifying, treating, and providing an appropriate referral to patients with opioid use disorders.
WORKS CITED https://qr2.mobi/opioid-use-disorde r
46
MDRI2026
Powered by FlippingBook