Is it safe to use opioids during the 2nd trimester of pregnancy?

From the Guidelines

Using opioids during the 2nd trimester of pregnancy is generally not recommended unless the benefits clearly outweigh the risks and they are prescribed by a healthcare provider. While the second trimester has lower risks than the first or third trimesters, opioid use during pregnancy can still lead to complications including neonatal abstinence syndrome (withdrawal in the newborn), potential birth defects, growth restriction, preterm birth, and stillbirth 1. If pain management is absolutely necessary, healthcare providers typically prescribe the lowest effective dose for the shortest duration possible, often preferring medications like acetaminophen as a first-line option.

Some key points to consider:

• All pregnant women should be screened for substance use at the first prenatal visit with the use of a validated questionnaire, such as the National Institute on Drug Abuse (NIDA) Quick Screen Tool 1.
• For opioid-naïve women, nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen, unless contraindicated, should be given as first-line treatments for pain after a routine vaginal birth or cesarean delivery 1.
• A short course of low-dose opioids can be considered for severe pain that is not managed effectively by nonopioid options 1.
• For women already dependent on opioids, abrupt discontinuation is not recommended as withdrawal can cause fetal distress; instead, medication-assisted treatment with methadone or buprenorphine under close medical supervision is the standard of care 1.

The risks occur because opioids cross the placenta and affect fetal development, potentially impacting the developing nervous system and other organs. Any pregnant woman requiring pain management should discuss all options with her healthcare provider to create an individualized plan that minimizes risks to both mother and baby. It's also important to note that postpartum pain should be managed with the use of a multimodal approach that starts with nonopioid pain relief, and if pain persists for >24 hours, a full opioid agonist may be ordered 1.

From the FDA Drug Label

Prolonged use of opioid analgesics during pregnancy can cause neonatal opioid withdrawal syndrome Published studies with morphine use during pregnancy have not reported a clear association with morphine and major birth defects Based on animal data, advise pregnant women of the potential risk to a fetus. Opioids cross the placenta and may produce respiratory depression and psycho-physiologic effects in neonates.

The use of opioids, such as morphine, during the 2nd trimester of pregnancy is associated with potential risks, including neonatal opioid withdrawal syndrome. While there is no clear association with major birth defects, animal data suggests a potential risk to the fetus 2. Therefore, opioids should be used with caution and only when the benefits outweigh the risks. It is recommended to advise pregnant women of the potential risk and to manage newborns for signs of neonatal opioid withdrawal syndrome.

From the Research

Opioid Use During Pregnancy

• There is limited research directly addressing the safety of opioid use during the 2nd trimester of pregnancy.
• However, studies suggest that opioids can be used for acute pain management under close clinical supervision, but the risks and benefits must be carefully considered 3, 4.
• The use of opioids for chronic pain is more controversial, with evidence suggesting that they may not improve function or quality of life beyond 3 months, and may lead to negative consequences such as tolerance, dependence, and hyperalgesia 5.
• Nonopioid alternatives, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen, may be effective for managing acute pain and can reduce the need for opioids 3.
• Combination therapy using a small amount of opioid together with a nonopioid pain reliever may be a safer and more effective approach for managing acute pain 3.

Considerations for Opioid Use in Pregnancy

• The risks of opioid use during pregnancy, including the potential for fetal harm and neonatal abstinence syndrome, must be carefully weighed against the benefits of pain management.
• Clinicians should consider alternative pain management strategies and closely monitor patients who require opioid therapy during pregnancy.
• There is a need for further research on the safety and efficacy of opioid use during pregnancy, particularly in the 2nd trimester 4.