The first time that I cared for a patient who was both recovering from drug addiction while experiencing acute pain, was in Labor and Delivery in 2014. Neither of us was prepared for this. We both exchanged the same shell-shocked, “What do we do now?” look several times that shift. I had a profound realization that day; I needed to come up with a better plan.

My initial idea was a literature search in Pubmed, a free national database of indexed citations and abstracts from thousands of science and healthcare journals. I also hit up Cochrane, a database that provides systematic reviews of evidence based medicine.

While it is difficult to get a good estimate on the prevalence of drug addiction in pregnancy, the National Institute on Drug Abuse published data in 2015 showing that 21,732 infants were born with Neonatal Abstinence Syndrome (NAS) in 2012. That’s equal to one baby being born every 25 minutes with this syndrome. That is a lot of potentially challenging labors to manage.

Ultimately, the most important take away from my research was “treat the pain, not the addiction”. While it’s never ideal to administer narcotics to a recovering addict without a bigger plan, it’s still superior than allowing a patient to suffer.

In an ideal world, the best plan is to have a pre-labor consultation with the patient and anesthesiologist. This can be tricky to make happen as pain control is rarely addressed (especially the kind that recovering addicts need) during the prenatal course. The opportunity for this most often occurs when women are induced, or come in for antepartum testing. I was fortunate enough that my recovering patient was having both of those.  I was able to broach the topic during an NST, and I then requested her when she came in for induction. We were both thankful that the anesthesiologist on that day was open to discussing a plan that she was comfortable with. Just talking together as a team helped her relax.

My patient at that time was taking methadone, which I learned while doing my nursing assessment. Since she had not taken a childbirth class, I gave her homework to research how methadone can both increase the body’s sensitivity to pain (hyperalgesia) as well as limit the options for other pain medications like Stadol, due to the opioid agonist therapy (OAT) she was in. By front loading her understanding of how her pain control was about more than just preventing a relapse, her expectations were set to be more informed as well as more realistic.

The plan that we all agreed upon involved several key areas:

• Set the expectation. While this falls under “patient education” it’s such a powerful tool that it bears having its own bullet point. Having a realistic and frank discussion about the realities of labor is important for any patient, and it should begin with prenatal care. As any L&D nurse can tell you, there is nothing more disheartening than a woman in labor demanding “the shot that takes all of the pain away”.
• Utilize non-pharmacological modalities as much as possible. I created a folder with childbirth information for her in which Penny Simkin figured prominently. Her free guide with illustrations of positions and easy to read mantras were the perfect shorthand for the situation. While we started her induction, we discussed the handouts together.
• Consult with anesthesia ASAP. Again, this can be difficult since you really need a doctor who is on board and .The plan that we came up with was for a labor epidural as soon as she wanted one. Thankfully, ACOG supports labor epidurals at any dilatation, and the evidence supports that receiving one “early” does not adversely affect labor outcomes. The other nuance was to administer the epidural without any opioids. No fentanyl mixed in, just Lidocaine and Bupivacaine. While the likelihood of the opioids placed in the epidural space crossing over into her circulation were pretty minimal, it was a very real concern for her, and we needed to respect that.
• Have a plan B. Should things not go according to plan go sideways, we needed to have a course of action nailed down. This included contacting the obstetrician and enlisting their support while also reminding them that a patient in OAT can require as much as 70% more opiates to manage pain (which she was willing to take should she need surgery) post-operatively. We also discussed a social services referral in this event to help provide services to prevent relapse.
• Provide continuous support. I have to say, this simple intervention was the most effective thing that I did. It helped that our census was low, and I had an understanding charge nurse.

In the end, a lot of stars aligned that day, as my patient was able to cope with the pain, receive an epidural, and ultimately give birth to a healthy baby girl.

Educating the patient, creating a team, and formulating a plan with the patient’s input, as well as providing continuous support, has guided me with the increasing number of patients that arrive in similar situations. This experience has also led me into many different discussions with other nurses and doctors.

The consensus has been that this growing population of patients is compelling enough to establish a pathway for care during labor.  Something we are working on and will hopefully provide a road paved with evidence based best practices in the near future. And while these patients are by no means representative of every person struggling with addiction (recovering or not) they allowed me to recognize a growing need, as well as to learn new ways of helping patients to cope with the dignity and compassion we all strive to provide for the patients we are caring for.

Search for these resources available in the AWHONN Online Learning Center 

• Opioid Use in Pregnancy: Detection and Support Webinar
• Breastfeeding Implications for Women Receiving Medication Assisted Treatment for Opioid Use Disorders Webinar

Tasha Poslaniec has been a registered nurse for 17 years. She has been working in obstetrics for over a decade and is currently a Perinatal Quality Review Nurse and Childbirth Educator.

She also writes about nursing and childbirth and has been published in the Huffington Post and the American Journal of Nursing. Pain control in childbirth has long been a topic of study and research for her.