Original Article: Primary Care for Persons Who Inject Drugs
Issue Date: January 15, 2019
See additional reader comments at: https://www.aafp.org/afp/2019/0115/p109.html
To the Editor: I appreciated this article, but the review did not include discussion of maternal or child health. As primary care physicians who care for the mother/child dyad, family physicians are uniquely situated to provide comprehensive and longitudinal care for women and children affected by substance use disorders.
As many as 85% of pregnancies in women with opioid use disorder are unintended.1 The rate of opioid use during pregnancy is 5.6 per 1,000 live births.2 In women with confirmed substance use disorder, physicians should discuss planning for pregnancy and offer the full spectrum of contraceptive options, including emergency contraception, and especially long-acting contraceptives.
The American College of Obstetricians and Gynecologists recommends using a verbal screening tool, such as the 4 P's (parents, partners, past, present), NIDA (National Institute on Drug Abuse) Quick Screen, or CRAFFT (car, relax, alone, forget, family, trouble), at the initial prenatal appointment.2 Screening should include alcohol, tobacco, and prescription and illicit drug use. Patients who screen positive for substance use disorder should be offered a brief intervention, motivational interviewing, and referral to treatment. Pregnant patients with opioid use disorder should have broadened sexually transmitted infection screening and should be screened for coexisting mental health disorders.1,3
The American College of Obstetricians and Gynecologists recommends opioid agonist therapy for pregnant patients with opioid use disorder.1 Opioid agonist therapy prevents withdrawal symptoms, prevents illicit use and associated morbidity and mortality, and improves adherence to prenatal care. The combination of prenatal care and opioid agonist therapy reduces the risk of obstetric complications. If the patient is already undergoing opioid agonist therapy with methadone, buprenorphine, or buprenorphine/naloxone film (Suboxone), that treatment plan should continue. Evidence is growing that extended-release injectable naltrexone (Vivitrol) is also safe to continue during pregnancy. Because the risk of relapse is high and withdrawal has been correlated with increased miscarriage rates, withdrawing from opioids is not recommended. If the patient insists on withdrawing from opioids, it should be done in a supervised medical setting.1,3
There has been a sharp increase in neonatal abstinence syndrome, from 1.5 cases per 1,000 hospital births in 1999 to 6 cases per 1,000 hospital births in 2013.4 Symptoms of neonatal abstinence syndrome include irritability; jitteriness; tremors; difficulty sleeping; being inconsolable; high-pitched crying; exaggerated Moro reflex; hypertonia; and myoclonic jerks. Poor feeding and weight loss may also occur in infants born to mothers with opioid use disorder. Breastfeeding and skin-to-skin contact improve symptoms, reduce the need for pharmacotherapy, and shorten neonatal hospitalization. Breastfeeding should be encouraged in patients who are stable on opioid agonists, not using illicit drugs, and have no other contraindications (e.g., HIV infection).5
In Reply: We appreciate Dr. Dakkak's commentary regarding our article. We agree that the myriad of possible adverse effects from injection drug use during pregnancy necessitates an evaluation for pregnancy status and a discussion of contraception options as part of the complete evaluation and care of these patients. Given the rising prevalence of opioid use disorder during pregnancy, a comprehensive review of opioid agonist pharmacotherapy during pregnancy, intrapartum and postpartum management, and neonatal abstinence syndrome would be of value to family physicians who often care for these patients.