April 15, 2014
News Review From Harvard Medical School -- More Pregnant Women Prescribed Opioid Pain Pills
The number of pregnant women in the United States being prescribed narcotic pain medicines has grown, says a new study. This is happening even though the risks to a developing fetus are unknown. Researchers looked at the pharmacy records of 1.1 million pregnant women receiving Medicaid. Between 2000 and 2007, the number of women filling a prescription for these drugs rose from 18.5% to almost 23%. Codeine and hydrocodone were most often prescribed. The prescription rates varied from 9.5% to 41.6% depending on the state. Another study published online in the journal Anesthesiology in February found similar results. The pregnant women in that study had private health insurance. The journal Obstetrics & Gynecology published the new study. HealthDay News and the New York Times wrote about it.
By Lori Wiviott Tishler, M.D.
Harvard Medical School
What Is the Doctor's Reaction?
I was at a dinner last week. One of my colleagues, expecting a baby in July, sent back the swordfish she was served in favor of a vegetarian option. She was appropriately worried about the mercury levels in the fish. She drank decaf. Pregnant women worry about the best way to take care of their health and the health of their fetuses. Doctors worry about the best way to care for pregnant women, especially when they need to prescribe medications.
When I counsel women who are newly pregnant, we always discuss medication. Drugs in pregnancy range from the rare class A (safe) to the less rare class X (definite harm to the fetus). We review the patient's medicines and discuss which medicines are safe to take, which are not safe, and which need more consideration.
Painkillers are an important part of that discussion. For most women, acetaminophen (Tylenol) is safe in pregnancy. Many medicines like oxycodone, opiates, are considered class B in pregnancy: They are not expected to harm a fetus. That's different than saying that they are safe for pregnant women and their fetuses!
The New York Times article reviews two recent studies that show that nearly one quarter of pregnant women filled an opioid prescription in 2007, which is a significant increase over the previous 10 years. Another study with a different population of women found lower, but still large, numbers. Most women took the medicine for a week or less.
Is this ok? It's hard to say. Tremendous regional variation exists. For women on Medicaid, 4 in 10 women in Utah received opioids during pregnancy. That compares with 1 in 10 women in Oregon and New York. Since it is hard to imagine that pregnancy in Utah is different than pregnancy in Oregon, regional variation helps physicians and researchers to say that this kind of care is not based on clear guidelines or good science.
While most people consider that opiates are relatively safe in pregnancy, some recent studies have suggested that neural tube defects, like spina bifida, are slightly more common in the children of women who took opioids early in pregnancy. Consistent opioid use at the end of pregnancy can cause addiction and withdrawal in the newborn.
Pregnancy is uncomfortable. Some physicians in the New York Times article speculated that rising obesity rates might be part of the reason for increased back pain during pregnancy. Experts speculate that it is often easier for physicians to prescribe a pill (and for patients to take one) than to engage in a more time-consuming process, such as physical therapy.
What I keep returning to as I read this article and considered these studies is the sense that we — doctors and patients alike — don't really know the answer to this question: What is the right way to ensure that we treat pregnant women's pain appropriately and what is too much?
What Changes Can I Make Now?
Over half the pregnancies in this country are unplanned. Preconception planning is really important to ensure a healthy pregnancy and healthy baby. Things to consider with your doctor before you get pregnant include:
- How will your overall health, medical history and surgical history impact you during pregnancy?
- What medications do you take? Is it safe to become pregnant on those medicines or should they be altered?
- Are you up to date on your vaccinations?
- Are you exposed to environmental risks at home or at work? Can those be changed or made safer?
- Are you taking prenatal vitamins, especially folic acid?
- Is your fetus at risk for any particular genetic diseases? Can you be tested for those? Does your husband or partner need to be tested as well?
These are all things that are easily done and can contribute to a healthy pregnancy. If you have an unplanned pregnancy, don't worry too much. But do talk with your doctor about these issues as soon as possible.
When you do become pregnant, talk with your caregiver about which over-the-counter medications, including ones like Tylenol, are safe for you to take. If offered stronger pain medicines, consider whether you need them or whether lifestyle things like a heating pad or physical therapy might help as well. Ask your doctor! If you have surgery or an accident, you might really need to take opioid medicines. In that case, the benefit will likely outweigh the risk, but ask good questions to ensure that you understand the pros and cons.
What Can I Expect Looking to the Future?
I hope we can expect lots of women to have lots of healthy babies! But there is this trend that more pregnant women are taking prescription pain drugs. We need to know how these drugs affect pregnant women. That's why more research is paramount.