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OPIOID USE IN PREGNANT & BREASTFEEDING WOMEN

Pregnant & Breastfeeding Moms
 
Guidelines for using opioid drugs to treat pain in women who are pregnant or breastfeeding:
 
Common types of prescription opioid drugs are oxycodone (Percocet), hydrocodone (Vicodin), morphine and methadone.
 
  • When choosing treatment for acute pain in mothers who are breastfeeding, non-opioid pain medicine like acetaminophen (Tylenol) should be used first.

  • Aspirin should be avoided, as it stays in mothers’ milk for up to 24 hours, and the newborn’s ability to break it down and get rid of it is slow.

  • Early breastfeeding by mothers who received opioid drugs during delivery results in little risk to the baby. However breastfeeding babies will be exposed to the drugs taken by their mothers.
    • To reduce drug transfer to the baby through breast milk, medicines should be taken after breastfeeding if possible, to increase the time between taking the medicine and breastfeeding.

  • The amounts of codeine and morphine in breast milk are equal to or somewhat more than the mother’s amounts.

  • While limited use of codeine is likely to be safe in breastfeeding mothers, regular use should be avoided.

  • Health care providers should use caution when prescribing oxycodone (Percocet) to breastfeeding mothers, especially in the first two months after delivery. Oxycodone may cause the baby to be too sleepy and difficult to wake up.

  • Normeperidine (from Demerol) can pass into breast milk.

  • Its half-life is much longer in newborns, so repeated use should be avoided.

  • Abruptly stopping opioid drugs that babies were exposed to in the mother’s womb can cause them to have withdrawal symptoms (trembling, irritability, excessive & high pitched crying, hyperactivity, tight muscle tone, sleep problems, seizures, poor feeding, vomiting, & diarrhea).
    • Breastfeeding should be encouraged in opioid-dependent mothers maintained on buprenorphine (Suboxone, Subutex): or methadone if there are no medical reasons to avoid breastfeeding with these exceptions:
      • urine drug screens positive for illicit drugs
      • positive HIV test
      • and/or other existing medical and/or psychiatric reasons to avoid breastfeeding

  • Health care providers should refer to existing guidelines and consult with a substance abuse treatment provider.

Resources:

  • AAP POLICY STATEMENT: Breastfeeding and the Use of Human Milk February 27, 2012  http://pediatrics.aappublications.org/content/early/2012/02/22/peds.2011-3552
    Adequately nourished narcotic dependent mothers can be encouraged to breastfeed if they are enrolled in a supervised methadone maintenance program and have negative screening for HIV and illicit drugs.

  • The Council on Patient Safety in Women's Health Care - Patient Safety Bundle on Obstetric Care with Opioid Use Disorder (+AIM) (addressing breastfeeding): 
    https://safehealthcareforeverywoman.org/patient-safety-bundles/obstetric-care-for-women-with-opioid-use-disorder/
    RESPONSE: Every provider/clinical setting/health system
    • Incorporate family planning, breastfeeding, pain management and infant care counseling, education and resources into prenatal, intrapartum and postpartum clinical pathways.
      • Provide breastfeeding and lactation support for all postpartum women on pharmacotherapy.
      • Provide immediate postpartum contraceptive options (e.g. long acting reversible contraception (LARC) prior to hospital discharge.

  • ACOG COMMITTEE OPINION: Postpartum Pain Management #742 2018
    C:\Users\nancyb\Downloads\ACOG_Committee_Opinion_No__742__Postpartum_Pain.56.pdf

  • ACOG COMMITTEE OPINION: Opioid Use and Opioid Use Disorder in Pregnancy Number 711 • August 2017
    https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co711.pdf

  • ABM Clinical Protocol #21: Guidelines for Breastfeeding and Substance Use or Substance Use Disorder, Revised 2015 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4378642/pdf/bfm.2015.9992.pdf
    • Women on stable doses of methadone maintenance should be encouraged to breastfeed if desired, irrespective of maternal methadone dose
    • Reduced severity and duration of treatment of Neonatal Abstinence Syndrome (NAS) when mothers on methadone maintenance therapy breastfeed
    • Buprenorphine (Suboxone, Subutex): breastfed infants had less severe NAS and were less likely to require pharmacological intervention than the formula-fed infants

      Opioid Agonist Pharmacotherapy = Medication Assisted Treatment
    • Prevents opioid withdrawal symptoms
    • Prevents complications of nonmedical opioid use
    • Improves adherence to prenatal care
    • Improves adherence to addiction treatment
    • Reduces risk of obstetric complications
    • Does lead to expected and treatable NAS in the infant

Breastfeeding should be encouraged in women who

  • are stable on their opioid agonist
  • not using illicit drugs
  • have no other contraindications (e.g. HIV+)


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5-22-19

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