Intrapartum and Postpartum Analgesia for Women Maintained on Methadone During Pregnancy
Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, and the Department of Statistics, University of Vermont College of Medicine, Burlington, VT 05401, USA. Obstetrics and Gynecology
(Impact Factor: 5.18).
09/2007; 110(2 Pt 1):261-6. DOI: 10.1097/01.AOG.0000275288.47258.e0
To determine whether methadone maintenance alters intrapartum or postpartum pain or medication requirements.
Sixty-eight patients treated with methadone for opiate dependence during pregnancy (vaginal n=35; cesarean n=33) were matched retrospectively to control women. Analgesic medication and pain scores (0-10) were extracted from the medical record. The primary endpoint was opiate use postpartum (oxycodone equivalents). The secondary endpoints were pain scores and intrapartum analgesia.
There were no differences in intrapartum pain or analgesia. After vaginal birth, methadone-maintained women experienced increased pain (methadone, 2.7 [1.9-5.0]; control, 1.4 [0.5-3.0], P=.001) but no increase in opiate use ([mean+/-standard deviation] methadone 12.7+/-32.1; control 6.8+/-12.7 mg/24 h, P=.33); after cesarean delivery both pain (methadone, 5.3 [4.1-6.0]; control, 3.0 [2.2-3.9], P=.001) and opiate use (methadone, 91.6+/-51.8; control, 54.0+/-18.6 mg/24 h, P=.001) increased.
Methadone-maintained women have similar analgesic needs and response during labor, but require 70% more opiate analgesic after cesarean delivery.
Available from: Benjamin Rolland
- "Or les prescripteurs sont encore peu familiarisés à cette démarche. Ainsi, une étude autrichienne, menée en double aveugle,  a récemment démontré qu'après une césarienne, les femmes recevant un TSO avaient moins accès aux traitements antalgiques opioïdes alors qu'il est démontré qu'elles en ont davantage besoin . La réticence des soignants vis-à-vis des traitements opioïdes a parfois été qualifiée d'« opiophobie » par certains auteurs . "
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ABSTRACT: Opioid maintenance treatments (OMT) reduce illicit opiate use and its associated risks. They are often prescribed on a long-term basis. Physiological changes induced by long-term OMT may cause hyperalgesia and cross-tolerance to opioid agonists, which suggests that the dosage of analgesic treatment should be modified in cases of acute pain, especially when an opioid-based analgesia is required. When treatment with analgesics is necessary, OMT must be maintained, except in exceptional cases. If a split-dosing schedule is temporarily employed during OMT, the daily dosage should not be increased for analgesic purposes. Analgesic treatment must be managed differently in case of treatment with buprenorphine or methadone. With buprenorphine, non-opioid analgesics should be introduced first, if possible. If this strategy is inefficient or contraindicated, a temporary or definitive switch to methadone should be considered. In the case of methadone-based OMT, opioid analgesics should be added directly and the dosage should be adapted according to the level of pain reported by the patient.
Available from: Reinhold Jagsch
- "Moreover , opioid dependent patients in methadone maintenance therapy seem to be more sensitive to pain than those opioid dependent patients maintained on buprenorphine (Compton et al., 2001). This experimental data is reflected by clinical investigations examining differences in pain management between opioid-dependent and non-opioid dependent pregnant women thus revealing higher pain scores and higher requirement of analgesics in the opioid dependent group in the postpartum period (Meyer et al., 2010, 2007). The analysis of the influence of the applied maintenance drug on postpartum pain revealed adequate pain control both in buprenorphine and methadone maintained women with standard treatment options, with drug-specific differences in the time course of the reduction of NSAIDs in the immediate postpartum period (Jones et al., 2006, 2009). "
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ABSTRACT: Increased pain sensitivity and the development of opioid tolerance complicate the treatment of pain experienced by opioid maintained pregnant women during delivery and the perinatal period. The aim of the present study was to investigate differences in pain management of opioid maintained compared to non-dependent pregnant women during delivery and the postpartum period. 40 deliveries of 37 opioid dependent women enrolled in a double-blind, double-dummy randomized controlled trial (RCT) examining the safety and efficacy of methadone (mean dose at the time of delivery=63.89mg) and buprenorphine (mean dose at the time of delivery=14.05mg) during pregnancy were analyzed and participants were matched to a non-dependent comparison group of 80 pregnant women. Differences in pain management (opioid and non-opioid analgesic medication) during delivery and perinatal period were analyzed. Following cesarean delivery opioid maintained women received significantly less opioid analgesics (day of delivery p=0.038; day 1: p=0.02), NSAIDs were administered more frequently to opioid dependent patients than to the comparison group during cesarean section and on the third day postpartum. Significantly higher nicotine consumption in the group of opioid dependent women had a strong influence on the retrieved results, and might be considered as an independent factor of altered pain experience. Differences in pain treatment became evident when comparing opioid maintained women to healthy controls. These differences might be based on psychosocial consequences of opioid addiction along with the lack of an interdisciplinary consensus on pain treatment protocols for opioid dependent patients.
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ABSTRACT: La prise en charge de la douleur chez le patient substitué est une situation complexe car la prise d’opioïdes à forte dose ne rend pas les patients insensibles à la douleur mais au contraire entraîne une sensibilité exacerbée à celleci. De plus, les particularités pharmacologiques des traitements de substitution (agoniste pur pour la méthadone et agoniste partiel pour la buprénorphine) imposent des prises en charge différentes en fonction du médicament de substitution. Cet article, après avoir souligné les particularités de la douleur chez le patient substitué, synthétise les stratégies pharmacologiques utilisables dans le cadre de la prise en charge de la douleur aiguë dans cette population particulière.
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