When Pain Doesn’t Stop with Delivery: Optimizing Peripartum Pain Management for Pregnant Patients with Opioid Use Disorder

Jordan Francke, MD, MPH

Pregnant patients who have a history of opioid use disorder (OUD) may present unique challenges to obstetric and anesthesia teams alike. Three experts reviewed special considerations for successfully managing this vulnerable population’s pain in the peripartum period and highlighted where questions still remain in a session cosponsored by Society for Obstetric Anesthesia and Perinatology (SOAP), “Optimizing Peripartum Pain Management for Pregnant Patients with Opioid Use Disorder: Consensus Statement from SOAP, ASRA, and SMFM,” held on Saturday, March 22 during the 2025 Annual Meeting, presented by IARS and SOCCA. Grace Lim, MD, MSc, Chief of the Division of Obstetric & Women’s Anesthesiology at the University of Pittsburgh Medical Center, moderated this engaging panel.

Brian Bateman, MD, MSc, Chair of the Department of Anesthesiology, Perioperative and Pain Medicine and Anesthesiology, Perioperative and Pain Medicine Endowed Professor at Stanford University, opened the session with a talk focused on “Scope of the Problem, Scope of the Evidence, and the Path Forward.” Dr. Bateman illustrated that as of 2023, approximately 3% of pregnant patients in the United States carry a diagnosis of OUD. In some states, including West Virginia and Vermont, this exceeds 10%. Many patients are managed with medications for OUD (MOUD), such as methadone or buprenorphine, which often require adjustments in the peripartum period. OUD may be associated with increased intolerance to standard opioids used peridelivery, and may also be associated with hyperalgesia, or an excessive sensation of pain to an already painful stimulus.

Patients with OUD often require higher doses of opioids after cesarean delivery, and often still have higher pain scores compared to patients without OUD. Once patients go home, the risk of a postpartum overdose remains high, and nearly 20% of pregnancy-related mortality may be attributed to opioid overdose. There is decidedly a paucity of literature on pregnant patients with OUDs, and most articles are literature reviews, case reports, or retrospective cohort studies. Randomized clinical trials (RCTs), the gold-standard in the scientific literature, are extremely challenging to implement in this population.

Patients may be less likely to participate given the stigmatized nature of OUD, their pregnancy status may contribute to a hesitancy to participate in scientific studies perceived as departing from “standard of care,” and consistent follow-up may also be more challenging in this patient population. Dr. Bateman conceded that while RCTs are unlikely to be feasible, well designed high quality observational studies may provide convincing evidence to fill this gap, but do require careful attention to bias.

Sarah Osmundson, MD, MS, Associate Professor in the Department of Obstetrics and Gynecology and Vice Chair of Research at Vanderbilt University, followed with a talk entitled, “Caring for Pregnant Patients on Medications for Opioid Use Disorder: Clinical Implementation Challenges and Strategies.” Dr. Osmundson provided an obstetrician’s perspective on the unique challenges patients with OUD face, particularly in the postpartum period. She argued that pregnant patients on MOUD require tailored peripartum pain management. Continuation of methadone and buprenorphine in the peripartum period is critical, and many patients require uptitration or fractionation of their daily dosages in the third trimester to reduce the likelihood of withdrawal. This may lead to worsening of medication-related side effects, including somnolence or corrected QT prolongation.

Dr. Osmundson highlighted that after vaginal delivery, most patients with OUD follow similar recovery paths to patients without OUD. At her institution, and many of its peers, patients recovering from vaginal delivery automatically receive multimodal nonopioid analgesia. However, she highlighted that patients with OUD should be maintained on their MOUD regimen, and that there may be a benefit to scheduling nonopioid multimodals compared to other patients for whom they may be ordered as PRN. Patients recovering from cesarean delivery often pose more significant challenges. These patients may require prolonged uptitration of their MOUD dosages, or abdominal wall blocks, to manage their postoperative pain. Dr. Osmundson encouraged the audience to involve a multidisciplinary team of nurses, anesthesiologists, and obstetricians when preparing a postoperative pain plan for patients with OUD.

Dr. Grace Lim closed out the panel with a summary of recommendations from the recent Consensus Statement on Pain Management for Pregnant Patients with Opioid-Use Disorder from the Society for Obstetric Anesthesia and Perinatology, the Society for Maternal-Fetal Medicine, and the American Society of Regional Anesthesia and Pain Medicine. She reminded the audience that these guidelines are based on mixed degrees of evidence, and thus each carry different classes of strength in terms of the recommendation. Highlights included the following: early neuraxial analgesia for patients with OUD should be standard, multimodal pain management (e.g., NSAIDs and acetaminophen) is the first-line for both vaginal and cesarean deliveries, MOUD should be continued in the peripartum period, abdominal wall blocks reduce opioid exposure in patients undergoing cesarean delivery, and a multidisciplinary and collaborative team approach should be employed to manage peripartum pain in patients with OUD.