Special Populations: Opioids and OB Patients(1) C.L.I.P.S. A Growing Problem ~23,000 pregnant women/yr on opiates in USA, 5x increase between 2000-2012, NAS affects about 1 in 175 babies Risks of Opioid Use in Pregnancy SAB or preterm labor with sudden withdrawal; intermittent withdrawal from heroin/short-acting opiates leads to SGA; neonatal abstinence syndrome (NAS) can occur w/ all opiates (legal or Rx’d) Treatment Options for Opioid-Dependent Pregnant Women **Do not wean unless on very small doses, in early preg and no addiction!** Methadone Pros: First-line standard of care for 40+ years. Improved compliance with prenatal care, better birth weights compared to ongoing opiate abuse. Cons: NAS can be slow to develop (72-96 hrs after birth). Requires daily dosing at methadone clinic. Turning Point is the only local residential txt program to accept pt’s on methadone. More side effects. Need for dose increases in 3rd TM. Buprenorphine- use without naloxone combo in pregnancy due to concern for fetal withdrawal if injected. Pros: A newer alternative to methadone that appears safe, can be Rx’d by physician, covered by PHP and M-cal in pregnancy. 2014 meta-analysis showed less need for NAS txt and shorter hospital stays for babies vs methadone. Cons: No long-term studies, cost after pregnancy sometimes an issue. Treatment of Chronic Pain in Pregnancy Acetaminophen 1st line, Ibuprofen safe in 2nd TM (and likely 1st), cyclobenzaprine Class B. Balance risks/benefits of TCA’s, gabapentin, SNRI’s, opiates. Non-pharma modalities all preferred. Resource: www.mothertobabyca.org How should patients on methadone or buprenorphine be counseled about pain management in labor? Options are the same (IV fentanyl, epidural). If have CS may need higher doses of narcotics PP to achieve analgesia. Continue maintenance doses of methadone or bupe throughout labor. References: Berghella V, Seligman N, Cleary B. Buprenorphine substitution therapy in pregnancy. UptoDate, 5/5/15 updated. Seligman N, Berghella V. Methadone maintenance therapy in pregnancy. Uptodate. 10/4/14 Updated. Brogly SB, Saia KA, Walley AY, Du HM, Sebastiani P. Prenatal buprenorphine versus methadone exposure and neonatal outcomes: systematic review and meta-analysis. Am J Epidemiol. 2014 Oct;180(7):673-86. Updated 2/16 E. Lund

What Opiate Side Effects are most dangerous in older adults? Pain & Opioids in the Elderly (2) C.L.I.P.S. Assessing Pain in the Elderly: Tendency to under-report, feel that pain is just a part of aging, tendency towards stoicism, fear of addiction if treated (though uncommon in this population) Pain may contribute to worsening frailty, functional decline, poor appetite, poor sleep, depression, anxiety, agitation and delirium in elderly pts. Perform comprehensive assessment, consider medical and psycho-social co-morbidities that will impact treatment Managing Pain: Use non-pharma treatments (PT, massage, acupuncture, joint or trigger pt injections, etc) prior to systemic therapy whenever appropriate Non-opioid Rx’s always preferred for non-cancer pain Acetaminophen generally 1st line, 2g/day max for pts who are frail or >80, caution pts about other drugs containing acetaminophen NSAIDs w/ caution in short term at low doses but contraindicated for >2 weeks for GI bleed and CV risks. Naproxen safest from CV standpoint. Avoid Ibuprofen in combo with low dose ASA. Risk of GIB is 2-4%/yr in elderly patients using chronically and PPI’s do not prevent. Antidepressants or anticonvulsants 1st line if neuropathic pain – SRNI’s usually better tolerated in elderly. If using TCA, desipramine or nortriptyline preferred in elderly pts as less likely to build up, titrate dose slowly, use lowest dose possible. Caution sedation SE’s. Opiates –Start with a 50% lower dose than you would in non-elderly pt due to increased sensitivity. Best options are oxycodone, morphine, hydromorphone, buprenorphine or fentanyl due to pharmacodynamics. What Opiate Side Effects are most dangerous in older adults? Mental status changes (sedation or cognitive impairment) Constipation Poor balance Respiratory depression/sleep apnea