Opioid Use in Pregnancy, Neonatal Abstinence Syndrome, and Childhood Outcomes: Executive Summary of a Joint Workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, American College of Obstetricians and Gynecologists, American Academy of Pediatrics, Society for Maternal-Fetal Medicine, Centers for Disease Control and Prevention, and the March of Dimes Foundation

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We read with great interest the article by Reddy et al.1 We applaud this comprehensive approach for care of pregnant women with opioid use and opioid use disorder.
We are concerned that the Joint Workshop did not include recommendations for patient education and advocacy regarding naloxone administration for pregnant and postpartum women on chronic opioids. Naloxone is approved by the U.S. Food and Drug Administration as an adjunctive medication to prevent overdoses of opioids. The American Medical Association, American Society for Addiction Medicine, Substance Abuse and Mental Health Services Administration, and the American College of Obstetricians and Gynecologists have highlighted that co-prescription of naloxone with chronic prescribed opioids and prescribing of naloxone in patients with opioid use disorder are critical components of preventing potentially fatal overdoses.2–5 To encourage this implementation, in 35 states and the District of Columbia, naloxone is now available without a prescription.6
The Joint Workshop concentrated on evidence-based guidelines for opioid prescribing, preventing opioid misuse, and treating opioid use disorder within pregnancy and the postpartum period. We believe the absence of mention of naloxone administration within the Joint Workshop recommendations misses the opportunity to advocate concurrent, recommended co-treatment of naloxone among pregnant and postpartum women at highest risk of overdose. Any administration of naloxone for opioid overdose should be followed by appropriate pain or addiction treatment services. Unfortunately, this often does not occur.7
We propose that obstetric providers are uniquely positioned to affect both maternal and neonatal adverse outcomes associated with over use of opioids and opioid use disorder. In Utah, drug-related death is now the leading cause of pregnancy-associated mortality (personal communication, L. Baksh, August 7, 2017). At our institution, Primary Children's Hospital, in the emergency room, 87% of pediatric overdoses from opioids occur in children under 5 years of age.
Training obstetricians to instruct pregnant and postpartum women on lifesaving interventions in the event of accidental overdose has the potential to drastically decrease maternal and childhood morbidity and mortality. Based on limited available data, naloxone administration is safe for both the pregnant woman and the developing fetus.8 We would encourage any comprehensive approach to care of pregnant women with chronic opioid prescriptions and opioid use disorders to include patient education on the administration of naloxone and advocate that pregnant and postpartum women have easy access to this life-saving medication.

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