Consensus statement on pain management for pregnant patients with opioid use disorder from the Society for Obstetric Anesthesia and Perinatology, Society for Maternal-Fetal Medicine, and American Society of Regional Anesthesia and Pain Medicine - 19/09/25

Doi : 10.1016/j.ajog.2024.12.006

Grace Lim, MD, MSc ^a,^⁎ , Brendan Carvalho, MBBS, FRCA ^b, Ronald B. George, MD ^c, Brian T. Bateman, MD, MSc ^b, Chad M. Brummett, MD ^d, Vivian H.Y. Ip, MBChB, MRCP, FRCA ^e, Ruth Landau, MD ^f, Sarah Osmundson, MD, MS ^g, Britany Raymond, MD ^h, Philippe Richebe, MD, PhD ⁱ, Mieke Soens, MD ^j, Mishka Terplan, MD, MPH, FACOG, DFASAM ^k
^a Department of Anesthesiology & Perioperative Medicine, University of Pittsburgh Pittsburgh, PA
^b Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University, Palo Alto, CA
^c Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, Ontario, Canada
^d Department of Anesthesiology & Pain Medicine, University of Michigan, Ann Arbor, MI
^e Department of Anesthesia and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
^f Department of Anesthesiology & Perioperative Medicine, Columbia University, New York, NY
^g Department of Obstetrics & Gynecology, Vanderbilt University, Nashville, TN
^h Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
ⁱ Department of Anesthesiology, University of Montreal, Montreal, Quebec, Canada
^j Department of Anesthesiology & Perioperative Medicine, Brigham & Women’s Hospital, Boston, MA
^k Friends Research Institute, Baltimore, MD

^∗Corresponding author: Grace Lim, MD, MSc.

Abstract

Pain management in pregnant and postpartum people with an opioid use disorder requires a balance among the risks associated with opioid tolerance, including withdrawal or return to opioid use, considerations around the social needs of the maternal-infant dyad, and the provision of adequate pain relief for the birth episode that is often characterized as the worst pain a person will experience in their lifetime. This multidisciplinary consensus statement from the Society for Obstetric Anesthesia and Perinatology, the Society for Maternal-Fetal Medicine, and the American Society of Regional Anesthesia and Pain Medicine provides a framework for pain management in obstetrical patients with opioid use disorder. The purpose of this consensus statement is to provide practical and evidence-based recommendations and is targeted to healthcare providers in obstetrics and anesthesiology. The statement is focused on prenatal optimization of pain management, labor analgesia and postvaginal delivery pain management, and postcesarean delivery pain management. Topics include a discussion of nonpharmacologic and pharmacologic options for pain management, medication management for opioid use disorder (eg, buprenorphine, methadone), considerations regarding urine drug testing and other social aspects of care for maternal-infant dyads, and a review of current practices. The authors provide evidence-based recommendations to optimize pain management while reducing risks and the complications associated with opioid use disorder in the peripartum period. Ultimately, this multidisciplinary consensus statement provides practical and concise clinical guidance to optimize pain management for people with opioid use disorder in the context of pregnancy to improve maternal and perinatal outcomes.

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Key words : adjuncts, analgesia, buprenorphine, cesarean delivery, medication for opioid use disorder, methadone, opioid use disorder, opioids, pain management, peripartum, prenatal, substance use disorder, urine toxicology, vaginal delivery

Plan

Introduction

Methods

Results and discussion

Prenatal optimization

Labor analgesia and postvaginal delivery analgesia

Cesarean anesthesia and postcesarean delivery analgesia

Summary of evidence: ketamine

Summary of evidence: gabapentin

Summary of evidence: clonidine

Summary of evidence: dexamethasone

Special consideration: opioid medications, disclosure and shared decisions, and urine toxicology

Conclusion

G.L. received salary and research support from the National Institutes of Health (NIH) under grants UH3CA261067, and R01MH134538. S.O. received support from the National Institute on Drug Abuse under grant numbers 5U01DA055347 and 5K23DA047476.

G.L. reports receiving salary and research support from the National Institutes of Health under grant numbers UH3CA261067, U01TR003719, and R01MH134538, receiving research support and consulting honoraria from and serving as a chair or member on the advisory board for Octapharma, Heron Therapeutics, Edwards Lifesciences, Haemonetics, and Werfen. G.L. further reports receiving stipends for medical expert testimony not related to this publication and receiving royalties from Cambridge University Press for a textbook. G.L. is a member of the Society for Obstetric Anesthesia and Perinatology board of directors and serves as a consultant reviewer for the American College of Obstetricians and Gynecologists (ACOG) and as American Society of Anesthesiologists liaison to the ACOG Alliance for Innovation on Maternal Health’s (AIM) Clinical and Community Advisory Group. C.M.B. reports serving as a consultant for Heron Therapeutics and Vertex Pharmaceuticals and a once-off consultation with the non-profit organizations Alosa Health and the Benter Foundation. C.M.B. also provides expert medical testimony.