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Opioid prescribing in the United States increased sharply in the late 1990s and early 2000s. This trend was largely based on the medical community’s response to the fear of neglecting to treat or to undertreat pain. In 2000, The Joint Commission on the Accreditation of Healthcare Organization (JCAHO) published guidelines urging practitioners to treat pain as the 5th vital sign

JCAHO pain management standards are unveiled.

Joint Commission on Accreditation of Healthcare Organizations. Phillips DM. JAMA. 2000 Jul 26;284(4):428-9

From 1997–2002, oxycodone use in the US rose over 400%.2 While less than 5% of the world’s population, Americans utilize 80% of the world’s opioid supply and 99% of the world’s hydrocodone supply.2 For many patients with opioid use disorder (OUD), their use began with an opioid prescription following an injury.4,5 In a CDC report in 2011, Medicaid enrollees are more than twice as likely as non-Medicaid populations to be prescribed an opioid analgesic and are six times more likely to die from an opioid overdose [].

For women's health providers, the data emerging on gender differences in OUD is alarming. Between 1999 and 2010, the increase in opioid-related mortality in women rose nearly 150% higher than in men.6 Mehta et al (2016) highlighted the dangers of substance use disorder among pregnant and postpartum women, citing drug overdose and substance-related injuries as the leading causes of maternal mortality.7

OUD is a chronic, relapsing neurobiological disease characterized by repetitive, nonmedical use of opioids despite physical and social consequences.1 Treatment of OUD with pharmacotherapy and recovery counseling dramatically reduces the risk of opioid-related overdose deaths.8 The American Congress of Obstetricians and Gynecologists (ACOG) recommends pharmacotherapy (methadone, buprenorphine) for treatment of OUD in pregnancy for the health of both mother and fetus.9,10 (Fig. 48-1)

FIGURE 48-1.

Data from American Society of Addiction Medicine: Defnition of Addiction. ( Accessed July 30, 2018.)



  • How do you diagnose acute opioid withdrawal in pregnancy?

  • What is the treatment for opioid withdrawal syndrome in pregnancy?

  • What are the key components of treatment for OUD in pregnancy?

CASE 48-1

A 21-y.o. G3P0 at 23 weeks GA dated by reported LMP presents to L&D triage with headache, nausea, vomiting, diarrhea, abdominal cramping, muscle aches, and irritability. She states that her symptoms have been worsening over the last 12–24 hours, and she could no longer tolerate it. She reports having been prescribed oxycodone for a sports-related ACL injury 2 years ago; reports receiving prescribed opioids by her PCP, ED physicians, and urgent care facilities over the last 2 years. Since disclosing her pregnancy, she has been unable to obtain a prescription and has been using oxycodone obtained ...

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