Antenatal Guidelines for Narcotic Administration

Contributor: MFM Division
Last Update: 4/18/2017

Due to the addictive potential of narcotics, judicial use of narcotic medications will be employed in managing OBTS patients.  Although the effects during organogenesis are not well known and no studies exist to suggest a strong link between maternal narcotic use and fetal malformation, withdrawal syndromes in both mother and neonate have been documented for over 30 years.  Maternal complications exist for women who abuse narcotics including increased risk for preeclampsia, third trimester bleeding, malpresentation, and meconium.  In addition, maternal long-term complications are numerous and include CNS degeneration, behavioral changes, neuropathy, and intellectual impairment.

To complicate the pregnancy, narcotic-exposed neonates may be at increased risk for SGA, IUGR, microcephaly, SIDS, apnea, and behavioral and neurodevelopmental delays.  Of greatest importance is the withdrawal syndrome termed Neonatal Abstinence Syndrome (NAS) that may require ultra-rapid or prolonged detoxification.  This condition is of great consequence to the infant and can last for as long as three months.

OBTS will employ the following standards when dealing with narcotic administration in the clinic:

• Patients who present initially for prenatal care and are already on maintenance methadone MUST continue to be managed by that primary care facility.  OBTS will NOT provide or manage methadone.  The patient must provide OBTS with medical documentation explaining the use and dose of methadone.  OBTS will ONLY write methadone in the event that the patient is hospitalized as to continue maintenance dosing.

• Patients who are seen by a Pain Management specialist or are cared for by another primary care physician, and are maintained on other narcotics must also make arrangements with that physician to continue maintenance/pain therapy.  An attending physician will attempt a verbal conversation with the primary care provider if there is difficulty with the patient continuing her care with the provider. In the event that the physician refuses to treat the patient during her pregnancy, the PATIENT must provide medical documentation from her physician explaining the need for maintenance narcotic/pain control including documentation of dosing regimen. The OBTS physicians will then review the documentation and at their discretion choose to continue or discontinue therapy.  If narcotic therapy for ongoing pain disorder is continued, the patient will be subject to random drug screening and will receive (as appropriate) narcotics on a scheduled basis during clinic visits only.  After the pregnancy, the patient must then return to her primary care physician to continue treatment.  

• Other use of narcotics among OBTS patients will be used sparingly, including drugs such as Fioricet and Lortab.  As a general rule, we will not be “new” prescribers of narcotics.  Narcotics will be used to adequately manage post-operative pain, post-operative complications, trauma victims, and early labor in the outpatient setting.  For migraines, patients may receive a one-time prescription for narcotics after trying alternative medications.  If the patient continues to require narcotics, she will immediately be referred to Neurology for evaluation of persistent headaches.  

• All other pain complaints will be evaluated on an individual basis.  Proper referral will be discussed at that time in order to ensure the cause of pain is being addressed.  Patients will also be referred to Mental Health for drug-seeking behavior or narcotic addiction as recognized by OBTS physicians.