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Opioid dependence and pregnancy: minimizing stress on the fetal brain

Published:November 25, 2016DOI:https://doi.org/10.1016/j.ajog.2016.11.1040
      To the Editors:
      The article by McCarthy et al
      • McCarthy J.J.
      • Leamon M.H.
      • Finnegan L.P.
      • Fassbender C.
      Opioid dependence and pregnancy: minimizing stress on the fetal brain.
      is informative and thought-provoking. The authors indicated there are 3 general sources of opioid dependence: untreated opioid use disorder, pain management, and medication-assisted treatment with methadone or buprenorphine. The increase in the number of opioid-dependent pregnant women delivering babies at risk for neonatal abstinence syndrome prompted a General Accountability Office report documenting deficits in research and provider knowledge about care of the maternal/fetal unit and the neonate. McCarthy et al
      • McCarthy J.J.
      • Leamon M.H.
      • Finnegan L.P.
      • Fassbender C.
      Opioid dependence and pregnancy: minimizing stress on the fetal brain.
      correctly pointed out that there have been efforts to criminalize maternal opioid dependence and to encourage or coerce pregnant women to undergo withdrawal in this country.
      In a recent article titled “Frustrated patients and fearful physicians,” Henry and Holt
      • Henry S.G.
      • Holt Z.B.
      Frustrated patients and fearful physicians.
      reasoned that decisions about opioids do not always fit neatly into the usual framework for medical decision making, because the associated risks and benefits span multiple domains that are both difficult to compare and hard to measure. Realistically, it is not just maternal opioid dependence that is criminalized; patients with chronic pain and addiction in general may also be criminalized.
      When opioids are involved, science alone is no longer enough. This can be seen that only 12% of individuals who entered custody on a methadone treatment program were maintained during their time of incarceration.
      • Ruan X.
      • Chiravuri S.
      • Kaye A.D.
      Science alone is not enough.
      In addition, there is a widespread chilling effect applied by governmental agencies on clinicians who practice opioid analgesia. In a recent editorial entitled “The pendulum swings for opioid prescribing,” von Gunten
      • von Gunten C.F.
      The pendulum swings for opioid prescribing.
      opined, “During my professional life as a physician, I have seen the pendulum of attitudes about the role of opioids for treating pain swing its full arc and back again…The newspapers are full of stories of the number of deaths from prescription opioids rising precipitously… The politicians are in a hurry to be seen to be ‘doing something’ and new laws and restrictions on prescribing are multiplying. I see the chilling effect on all prescribers every day. The meta-message to physicians is clear–be very afraid if you prescribe any opioids to anybody or you will cause them to be an addict and die. Better to let the patient suffer than be suspected of causing a rise in the number of addicts and opioid-related deaths. The pendulum is hurtling back to the place it had in 1940.”
      • von Gunten C.F.
      The pendulum swings for opioid prescribing.
      Under such a social current, are physicians to blame?

      References

        • McCarthy J.J.
        • Leamon M.H.
        • Finnegan L.P.
        • Fassbender C.
        Opioid dependence and pregnancy: minimizing stress on the fetal brain.
        Am J Obstet Gynecol. 2016 Oct 8; (pii: S0002-9378(16)30866-3)
        • Henry S.G.
        • Holt Z.B.
        Frustrated patients and fearful physicians.
        J Gen Intern Med. 2016 Sep 29; ([Epub ahead of print])
        • Ruan X.
        • Chiravuri S.
        • Kaye A.D.
        Science alone is not enough.
        Am J Med. 2016; 129: e249
        • von Gunten C.F.
        The pendulum swings for opioid prescribing.
        J Palliat Med. 2016; 19: 348

      Linked Article

      • Opioid dependence and pregnancy: minimizing stress on the fetal brain
        American Journal of Obstetrics & GynecologyVol. 216Issue 3
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          Increase in the number of opioid-dependent pregnant women delivering babies at risk for neonatal abstinence syndrome prompted a US Government Accountability Office report documenting deficits in research and provider knowledge about care of the maternal/fetal unit and the neonate. There are 3 general sources of dependence: untreated opioid use disorder, pain management, and medication-assisted treatment with methadone or buprenorphine. A survey of methadone patients’ experiences when telling a physician of their pregnancy and opioid dependence demonstrated physician confusion about proper care, frequent negative interactions with the mother, and failures to provide appropriate referral.
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