Opioid Use and Opioid Use Disorder in Pregnancy

Physiology and Pharmacology of Opioid Use

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Opioids diminish the intensity of pain signals and are generally prescribed for the treatment of pain, although cough and diarrhea are other indications for their use. Opioids have the additional effect of causing a sense of euphoria, which can lead to their misuse 17. Opioid use disorder may develop with repetitive use of any opioid, particularly in individuals with an underlying genetic vulnerability. Heroin is a rapidly acting opioid that may be injected, smoked, or nasally inhaled 18. Heroin has a short half-life, and to avoid opioid withdrawal symptoms, a physically dependent heroin user will need to take multiple doses daily. Prescribed opioids such as codeine, fentanyl, morphine, methadone, oxycodone, meperidine, hydromorphone, hydrocodone, propoxyphene, and buprenorphine all have the potential for misuse. These products may be swallowed, injected, nasally inhaled, smoked, chewed, or used as suppositories 19. The onset and intensity of effect will vary based on how the drug was taken and the formulation; however, all have the potential for causing respiratory depression, overdose, and death. The risk of respiratory depression, overdose, and death is greater for full opioid agonists (such as fentanyl) than for partial agonists (such as buprenorphine). Injection of opioids also carries the risk of cellulitis and abscess formation at the injection site, sepsis, endocarditis, osteomyelitis, hepatitis B, hepatitis C, and HIV infection. Sharing of snorting implements also has been identified as a risk factor for hepatitis C and other virus transmission in a group of pregnant women with hepatitis C 20.

Regular, long-term use of any opioid leads to predictable physiological dependence, which results in symptoms of withdrawal upon discontinuation of the drug. Typical symptoms of opioid withdrawal include generalized pain, muscle pain, nausea, diarrhea, sweating, rhinorrhea, tearing, dilated pupils, tremor, gooseflesh, restlessness, and anxiety. With short-acting opioids, such as heroin, withdrawal symptoms may develop within 4-6 hours of use, peak at 1-3 days, and gradually subside over a period of 5-7 days. For long-acting opioids, such as methadone, withdrawal symptoms usually begin within 24-36 hours of use and may last for several weeks. Unlike alcohol withdrawal, opioid withdrawal is rarely associated with severe morbidity and can be readily treated.

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