Opioid use disorder during pregnancy

Shannon C. Miller, MD, FASAM, FAPA, Medical Director, Integrated Dual Diagnosis and Outpatient Addiction Psychiatry/Medicine, Program Director, VA Advanced Fellowship in Addiction Medicine/Research, Veterans Affairs Medical Center, Cincinnati, Associate Professor of Clinical Psychiatry, Associate Director of Education, Training, and Dissemination, Center for Treatment, Research, and Education in Addictive Disorders (CeTREAD),Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH

Lisa Fernandez, MD, Addiction Psychiatry Fellow, University Hospital/University of Cincinnati, CeTREAD, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH

Roberto Soria, MD, Medical Director, Opiate Addiction Recovery Services, Assistant Professor of Clinical Psychiatry, Co-Director, Clinical Services, CeTREAD, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati, Cincinnati, OH

Early identification of opioid use disorder (OUD) in pregnant women can be challenging. Self-reports underestimate use and shame, fear of prosecution or involvement of child welfare services, and guilt can further erode self-report. Women with OUD may have irregular menses and might not be aware of their pregnancy until several months after conception. Also, women with OUD who are maintained on opioid agonist therapies may misinterpret early signs of pregnancy—such as fatigue, nausea, vomiting, headaches, and cramps—as withdrawal symptoms and may respond by increasing their opioid dosing, thus exposing their fetus to increased drug levels. Finally, many women with OUD experience amenorrhea as a result of their stressful, unhealthy lifestyle, which may preclude pregnancy despite sexual activity. When these women later enroll in an opioid maintenance program, their endocrine function may return to normal, leading to unexpected pregnancy.

Screening for OUD in pregnant patients has not been well studied. An interviewer’s nonjudgmental, empathic attitude may be more important than the specific questions he or she asks. It may be best to begin with less threatening questions and proceed to more specific questions after developing a therapeutic alliance.

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