Opioids after delivery: Addressing postpartum pain relief without feeding addiction

At least half of the states in the U.S. have enacted restrictions of some sort on opioid prescribing as part of our national effort to combat the opioid epidemic.

Appropriately, many of these limitations don’t apply in certain circumstances, such as for patients with cancer, in hospice or palliative care, or who are being treated in hospitals or during emergencies. And although increasing attention is being paid to women misusing opioids during their pregnancy – the National Governors Association is focusing on high rates of Neonatal Abstinence Syndrome (NAS) in one of several initiatives – relatively little focus is on how the epidemic is playing out in Labor and Delivery.

In our work through Ob Hospitalist Group (OBHG), which staffs hospitals across the country with OB/GYN clinicians who provide round-the-clock hospital-based obstetric coverage, we’re able to identify patterns that may not be evident at the sole facility level. Many of our observations about the national landscape are magnified in what our physicians are seeing in Arkansas, one of the states for which I serve as Medical Director. Data show Arkansas has one of the highest per capita opioid consumption rates in the nation.

Overwhelmingly, we’re seeing more women routinely asking for narcotics after delivery – especially women who haven’t had access to prenatal care services. Our takeaways on how we address these issues may be instructive for physicians, department heads and hospital administrators, as they inform strategies to address postpartum pain relief (including for C-sections) when there is suspicion of addictive behavior.

Wear many hats -- including as pediatrician and administrator stand-in. ACOG has issued clinical guidance for the care of pregnant women with opioid dependency and opioid use disorder, and generally is encouraging providers to say no to narcotics for vaginal delivery. This is similar to the policy that we have adopted at OBHG; in light of the increases in requests, we are limiting prescribing.

But most women presenting at antepartum aren’t overtly saying that they are using opioids. That’s when we have to be good detectives as well as good physicians. Babies born with NAS have greater health needs, such as seizures, that require long hospitalizations. Many, but not all, hospitals have standard policies that apply to all admissions that specify triggers for a maternal urine drug test. Those triggers often include no or limited prenatal care, a prior positive toxicology screen, and /or observed behaviors. Newborns can generally be tested if the mother declines testing and there is cause for concern; if the mother has a positive toxicology screen; and/or if the baby exhibits signs or symptoms of withdrawal. Physicians should follow these policies to the letter to help pediatricians identify babies with NAS as quickly as possible.

To underscore the need to also think like an administrator, consider that a 2012 JAMA study found that the average hospital costs for newborns suffering from NAS were five times greater than other hospital births. So testing as early as possible is for everyone’s benefit.

Never assume physician instruction is taken as the final word. Our OBs report that they’ll sometimes spend 20 or 30 minutes with a patient, explaining why they can’t provide narcotic pain relief. The patient generally nods and agrees. The minute the physician leaves the room, the patient buzzes the nurse and asks for meds. This behavior, driven not by duplicity but by dependence, makes it even more critical that all members of the care team – and especially the nursing staff -- are aligned on what the physician orders are, and any conditions for which opioid prescriptions are appropriate and allowable.

Be wise to greater tolerance. Opioid-dependent pregnant women have a higher tolerance for prescription pain relief. Considering cases where pain can be relieved by Tylenol or other non-opiate support in a non-dependent patient, physicians must be highly conscious of this tolerance in the dependent one.

The best way to handle these cases is proactively. OBs should set expectations about narcotic pain relief as soon as the patient arrives in the OB emergency department. They can also make sure all orders prescribing opioids follow ACOG recommendations, and that orders clearly dictate only NSAIDs and Tylenol for additional pain relief.

Additionally, a 2015 study notes that, “Pregnancy is a unique opportunity to identify opioid dependence, facilitate conversion to opioid maintenance treatment, and coordinate care among specialists in addiction medicine, behavioral health and social services.” Pain medication tolerance at delivery is a red flag to start these conversations in an empathetic, non-judgmental, and supportive manner.

As clinicians and health systems seek to balance the need to provide legitimate pain relief with the scourge of the opioid epidemic, we will need to continue to share key learnings and best practices to provide empathetic, professional, and safety-centered patient care.

Dr. Bashuk is Medical Director of Operations for Ob Hospitalist Group, the nation’s largest provider of OB hospitalist programs. A Board Certified OB/GYN, Dr. Bashuk is licensed in Arkansas and Georgia.

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