Concern Over Widespread Use Of Opioids In Pregnancy – A Warning To Patients
This past week the Center for Disease Control (CDC) released alarming statistics for opioid use in reproductive age women. Data looking at this group of women during the years 2008 to 2012 revealed that more than a third enrolled in Medicaid and more than a quarter with private insurance filled a prescription for opioid medication. These statistics are compounded by the fact that currently, 50% of births in the United States occur among women enrolled in Medicaid.
The CDC also found that each year, an average of three opioids was prescribed for every four privately insured women and nearly two opioid prescriptions for every one Medicaid-enrolled woman. Given that close to half of all pregnancies are not planned, and most are not recognized until well into the first trimester, this places many early pregnancies at risk. An analysis of prescription patterns by region showed opioid prescription rates were highest for reproductive-aged women living in the South and lowest for those residing in the Northeast.
Studies on the use of opioids in pregnancy suggest that these medications might increase the risk of neural tube defects (major defects of the baby’s brain and spine), congenital heart defects and gastroschisis (a defect in the baby’s abdominal wall). Multiple studies have shown an odds ratio of 1.7 to 2.9 for the risk of central nervous system anomalies including spina bifida and anencephaly for first-trimester opioid use. There are no reports of neuro-cognitive developmental abnormalities in children exposed to opioids in utero.
All of these studies, however, have significant limitations in design and some show conflicting results. Most are retrospective and rely on patient recall after the birth of an affected child. Often, the indication for the opioid is unknown. The reason for the medication may, in fact, contribute to the risk of birth defects rather than the medication itself. In addition, opioids are often combined with other medications including Tylenol and non-steroidal anti-inflammatory drugs (NSAID).
Another concern is heavy or chronic use of these medications during pregnancy which can lead to neonatal abstinence syndrome (NAS). NAS occurs when at birth, a newborn undergoes withdrawal symptoms from the opioids taken by the mother during pregnancy.
It is important for all providers to access opioid use in patients attempting or at risk of becoming pregnant. However, how should we counsel those pregnant patients taking opioids? We know that the background risk of major structural malformations at birth is 3%. Also, of the malformations identiﬁed at birth, approximately 10% of them are in fact caused by teratogens. While these past reports looking at opioid use in pregnancy give an estimate of effect, their study designs make it is impossible to calculate an absolute risk to the patient. Despite their limitations, given the number reports, and the large numbers of patients included in these reports, it is likely there is at least a slight increase in certain cardiac malformations, spina bifida and possibly gastroschisis with the use of opioid drugs in the first-trimester of pregnancy. As is true with any medication prescribed during pregnancy, it is important to review the risks and benefits of these medications with the patient, and when continuation is deemed necessary, to use the lowest effective dose. An excellent resource for patients is provided by the website provided by the Organization of Teratology Information Specialists (OTIS). Patients who require these medications during early pregnancy should be offered timely, non-invasive screening for fetal anatomic anomalies.
Patient Fact Sheet On Opioids In Pregnancy:
Ailes, E. C., Dawson, A. L., Lind, J. N., Gilboa, S. M., Frey, M. T., Broussard, C. S., and Honein, M. A. Opioid Prescription Claims Among Women of Reproductive Age – United States, 2008-2012. MMWR Morb.Mortal.Wkly.Rep. 64(2), 37-41. 1-23-2015.
Broussard, C. S., Rasmussen, S. A., Reefhuis, J., Friedman, J. M., Jann, M. W., Riehle-Colarusso, T., and Honein, M. A. Maternal treatment with opioid analgesics and risk for birth defects. Am.J.Obstet.Gynecol. 204(4), 314-11. 2011.
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