Prescribing opioids and psychotropic drugs in pregnancyBMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3616 (Published 02 August 2017) Cite this as: BMJ 2017;358:j3616
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I agree with the Editorial of AW Patrick et al. . Until now, there has been no clinical guidance and no comprehensive, evidence informed strategy regarding opioid use in pregnancy in any time period (pre-, peri-, postpartum). The main reasons are that opioid dependent patients often are dependent on the illegal consumption of heroin and, in addition, have a polytoxicomanic way of consuming drugs and are suffering from various somatic and psychiatric diseases, potentially life threatening . General clinical recommendations are to discontinue them, especially during the first trimester .
But the problems are more complex and difficult. Interdisciplinary care during pregnancy and afterwards by all the professions involved like general practioners, social workers, gynaecologists , paediatrists and psychiatrists should be ensured. With respect to the particular consumed drug substances other than opioids during pregnancy, variable forms of teratogenic and toxic effects can be assigned to the baby. Critical values of maternal substance abuse referring to fetal impairment do not exist. With regard to the possible teratogenic and toxic fetal effects of maternal consumption of alcohol, tobacco, sedativa, cannabis, cocaine and amphetamines, withdrawal treatment of polytoxicomanic pregnant patients need medical supervision and, if it´s possible, detoxication also by outpatient treatment. However, referring to heroin addiction, maintenance therapy with L-methadone, D/L-methadone or buprenorphine should be preferred since fetal withdrawal symptoms of opioids can otherwise cause severe complications.
In contrast, guidelines for prescribing opioids for chronic pain , for example, exist with exact recommendations and information on risk dosage to 50 morphine milligram equivalents/d, prescription drug monitoring programs, high-risk combination warning and evidence-based treatment, such as medication-assisted treatment with buprenorphine or methadone, and avoiding concurrent drugs and benzodiazepines.
I´m afraid, the case for women to be given opioids in pregnancy is weak.
1 Patrick SW et al. Prescribing opioids and psychotropic drugs in pregnancy. BMJ 2017;358:j3616
2 Chisolm MS, Payne JL. Management of psychotropic drugs during pregnancy. BMJ. 2016 Jan 20;532:h5918. doi: 10.1136/bmj.h5918.
3 Wong S et al.Substance use in pregnancy. 10.1097/AOG.0000000000002229. J Obstet Gynaecol Can. 2011 Apr;33(4):367-84.
4 Dowell D et al. CDC Guideline for Prescribing Opioids for Chronic Pain--United States, 2016. JAMA. 2016 Apr 19;315(15):1624-45. doi: 10.1001/jama.2016.1464
Competing interests: No competing interests