Pregnant women are often scrupulous about what they put in their bodies, avoiding alcohol, caffeine, processed meats and mercury-laced fish in an effort to protect their developing child. But if they go to their doctor for pain, about one in five will leave with a prescription for a narcotic painkiller such as codeine, hydrocodone or oxycodone, according to a recent study published in the journal Obstetrics & Gynecology. That’s a record number.
What’s wrong with this picture? Maybe nothing. Maybe a lot. The problem is we just don’t know for sure.
Although painkillers can be used safely during pregnancy, studies on the topic are limited, and that means our knowledge is limited. The research we do have indicates that children of mothers who used opioids in the first trimester have a doubling of the risk of neural tube defects. These are rare, however – 5.9 per 10,000 births. We also know that if opioids are used consistently at the end of a pregnancy, the child may be born addicted.
Dr. Lori Wiviott Tisher of Harvard Medical School wrote about the issue, noting that opioids like oxycodone are in a class of drugs that are not expected to harm a fetus, but “that’s different than saying that they are safe for pregnant women and their fetuses.”
Opioid Use Then and Now
So what do we know about opioid painkillers? They are powerful, can be addictive, and until the 1990s, they were used sparingly, usually for cancer patients and those who needed end-of-life pain relief. But after studies showed that they could be effective in relieving non-cancer pain, prescriptions increased tenfold. Broken down per person, average sales of opioids jumped 402 percent between 1997 and 2007.
Along with increased use came an increase in addictions, the trend toward recreational use, and our current prescription drug abuse epidemic. In 2009, the National Survey on Drug Use and Health found that almost 2 million Americans abused or were addicted to prescription pain relievers.
In short, painkillers should not be taken lightly. But, in the U.S. at least, that’s what appears to be happening. Consider this statistic: The U.S. has just under 5 percent of the world’s population yet it consumes 80 percent of the opioid supply. Do we really have a global monopoly on pain?
What the Studies Say
To track opioid prescription trends in maternity care, a group of researchers looked coast to coast at 1.1 million pregnant women enrolled in Medicaid. They found that:
- Nearly 23 percent of the women in the study filled a prescription for an opioid painkiller in 2007 – a record number – up from 18.5 percent in 2000.
- Prescription rates varied widely from region to region. In Utah, for example, 41.6 percent of pregnant women were prescribed opioids. In contrast, Oregon’s rate was 9.5 percent.
- Most women took the prescription for only a few days; about 2 percent took them longer.
An earlier study published in Anesthesiology looked at 500,000 privately insured women and found similar trends. Overall, 14.4 percent of women filled a prescription for opiate painkillers at least once during their pregnancy, and the numbers varied by region. Both of the studies’ authors pointed to a need for additional research.
What’s Behind the Prescription Drug Numbers?
In their wake, the studies leave questions. Why are the regional differences in prescription rates so dramatic? Pain itself probably doesn’t fluctuate dramatically from state to state. At the very least, the numbers point to a need for consistent education for doctors nationwide about opioids and their risks. The White House attempted to do just that in 2011, with a call for mandatory training for doctors who prescribe narcotic painkillers. But the FDA, overriding the advice of an expert panel, decided instead to institute a voluntary education program funded by the companies that make the drugs.
What is prompting the record number of prescriptions? Is the push coming from the patients themselves, who are naturally seeking tangible relief? And are doctors, who now face the pressure of “patient satisfaction” ratings, succumbing to a desire to please a patient who is hurting? Or is it simply easier for busy doctors to write a prescription rather than talk to the patient about options?
Does a lack of options play into the numbers? Even acetaminophen, the traditional go-to pain reliever for pregnant women found in products such as Tylenol, comes with concerns. A recent study reported that children of women who took acetaminophen while pregnant were about 40 percent more likely to be diagnosed with attention deficit hyperactivity disorder (ADHD) than those whose mothers took none.
Alternative treatment such as physical therapy, acupuncture, massage and chiropractic adjustment can sometimes help with the discomforts of pregnancy, but what of those who suffer from extreme sciatica or pelvic girdle pain or who have pain issues unconnected to the pregnancy? Are they expected to suffer in silence? Untreated or poorly treated chronic pain is associated with anxiety, depression and hypertension-none of which is good for a developing child.
Building Better Care for Pregnant Women
There are no easy answers, but it’s clear the time has come to rethink how we medicate pregnant women. Some needed steps:
- More research is needed into the impact of opioids on pregnant women. According to the Centers for Disease Control (CDC), “Less than 10 percent of medications approved by the U.S. Food and Drug Administration (FDA) since 1980 have enough information to determine their risk for birth defects.” Research is also needed on developing alternate pain therapies for pregnant women.
- Doctors need better guidance, education and training before they are allowed to prescribe opioid painkillers, and they shouldn’t depend solely on pharmaceutical companies for the information. The industry is, after all, a business and one that spends enormous amounts of time and money promoting its products to those who prescribe them. It’s also time for more government oversight, such as a nationwide prescription drug monitoring database.
- Women need better information about the risks of narcotic painkillers and possible alternatives. (A good place to start is “Treating for Two,” a clearinghouse of maternity health news set up recently by the CDC.) In some cases, opioid painkillers may be the right choice; other pain may respond well to drug-free therapies. The key is to talk to your doctor about options and potential risks before he or she reaches for the prescription pad.