KL is a 20-year-old Caucasian woman who presented to the Emergency Department with complaints of opioid withdrawal. She discovered she was pregnant by home pregnancy test a month earlier, but had not yet sought care. She moved back to the area the previous day after leaving a physically abusive relationship, was without transportation, and was homeless and temporarily staying with a friend.
KL disclosed using Suboxone (buprenorphine/naloxone) 8 mg daily, supplied by her boyfriend, since learning she was pregnant. Her last use of illicit Suboxone was 2 days prior. In the year prior to this, she used up to 100mg of oxycodone by nasal insufflation (snorting) daily. She reported that her opioid use began when she was prescribed narcotics for tooth pain and found quickly that she liked the way they made her feel, including decreasing her persistent hypervigilance and insomnia. She transitioned herself to illicit Suboxone after learning she was pregnant, at the advice of a friend, and said that Suboxone helps her "to feel normal". She also disclosed cannabis use 3-4x per week, for anxiety and pregnancy-related nausea, and smoking 20 tobacco cigarettes daily. This is her second pregnancy. Her past medical history was significant for a recent pregnancy loss at 12 weeks after her boyfriend pushed her down a flight of stairs, childhood sexual trauma, and untreated posttraumatic stress disorder (PTSD).
KL's vital signs in the Emergency Department were: temperature 98.9 F, pulse 80, respiratory rate 18, blood pressure 96/58. The fetal heartbeat was reassuring at 160 bpm. She measured about 16 weeks pregnant. A voluntary urine drug screen was positive for cannabis and buprenorphine, consistent with her self report of recent use. She was visibly anxious on exam and exhibited signs of moderate opioid withdrawal on the Clinical Opiate Withdrawal Scale (COWS) including restlessness, dilated pupils and diaphoresis (excessive perspiration). She reported myalgia (muscle pain), diarrhea, and difficulty sleeping.
The earliest available appointment for the following week was made at an outpatient addiction treatment program because inpatient substance use disorder treatment was not readily available. Clonidine 0.1 mg every four hours and promethazine 25 mg three times daily were prescribed for symptom relief. KL was counseled about the potential effects of continued substance use and withdrawal on the pregnancy and instructed to call if she experienced abdominal pain, cramping, or bleeding. She was discharged to the care of her friend.
Early the following morning, KL called the hospital reporting weakness, syncope (fainting), and loss of vision. She was instructed to present to the emergency department immediately and not to drive. She arrived by ambulance, profoundly hypotensive (blood pressure 70/38, pulse 50), weak, pale, and diaphoretic (sweaty). She was placed on cardiorespiratory monitoring, treated aggressively with intravenous fluids, oxygen, and other supportive measures. After 12 hours, her blood pressure improved to 90/48 and she was no longer bradycardic (having a slow heartbeat). When she began to feel better, she disclosed that she took three additional clonidine tablets the previous evening to attempt to alleviate nightmares and associated anxiety. KL was seen by a consulting psychiatrist and found to exhibit symptoms consistent with posttraumatic stress disorder (PTSD), but did not meet requirements for inpatient psychiatric hospitalization. Bedside ultrasound revealed a viable intrauterine pregnancy at 17 weeks. Once stable medically, she was discharged with instructions to discontinue clonidine and follow up with the outpatient addiction treatment program as planned.
When seen the following week at the outpatient addiction treatment program, KL enrolled in the medical center's comprehensive perinatal addiction treatment program, which included weekly group and individual counseling. She disclosed that she continued to use illicit Suboxone and cannabis and no other substances (consistent with her urine drug screen that day), so was not currently experiencing opioid withdrawal symptoms. She elected to begin medication-assisted treatment and was started as an outpatient on buprenorphine for her opioid use disorder. KL received a full psychiatric evaluation and was diagnosed with PTSD as well as tobacco use disorder. She elected to begin sertraline for PTSD, received smoking cessation counseling, and declined a prescription for nicotine replacement gum, preferring to try to reduce smoking without it.
KL attended treatment weekly for the remainder of her pregnancy, including regular attendance at group counseling sessions and kept all appointments for medication management. Over the course of her pregnancy, her buprenorphine dose was gradually increased from 8 mg to 16 mg to achieve symptom control. Cigarette use was assessed during medication follow up visit and she was counseled using the "5 A's" technique (ask, advise, assess, assist, arrange). Sertraline was titrated to 100 mg daily and PTSD symptoms improved. With counseling from her providers, she was able to taper her cigarette use to 5 cigarettes daily, but was unable to stop completely. After meeting with the domestic violence advocate, she had no further contact with the father of her pregnancy. KL received support from the program's social worker and was able to move into subsidized housing during the third trimester of her pregnancy.
KL received regular prenatal care from the nurse midwife who was co-located at the addiction treatment program each week. Her symptoms of nausea were controlled with promethazine and she discontinued cannabis use. KL had a normal pregnancy course and delivered a healthy 3000 gm (~6 lbs, 10 oz) infant at 39 weeks. Her infant required treatment for neonatal abstinence syndrome (withdrawal syndrome observed in babies exposed to opioids in utero) from postnatal days 4-6 and was discharged on day 8. KL stayed with him for the duration of his hospitalization, and breastfed successfully with the support of nurses and certified lactation consultants experienced with the management of breastfeeding in the context of neonatal abstinence. Postpartum, she was transitioned from buprenorphine monotherapy to combination buprenorphine-naloxone and continued in the treatment program.
In the discussion below, we review existing evidence supporting components of care for pregnant women with opioid use disorder and co-occurring posttraumatic stress disorder. These include the prenatal treatment of opioid physiologic dependence and/or withdrawal; psychotherapeutic approaches commonly used during pregnancy; and the benefits and risks of pharmacologic approaches for treating opioid use disorder and comorbid PTSD. Finally, we call for a collaborative approach across disciplines to provide access to comprehensive treatment.