Balance in opioid prescription during pregnancy.

1063 May 2014 I N this issue of ANesthesiology, Bateman et al.1 present an analysis of opioid prescription practices from a large U.s. private insurance database. The information derived from the database “inVision” for Data Mart is constructed from medical and prescription information from privately insured people in the United states. The authors identified a surprisingly high incidence of opioid prescription during pregnancy (14%) which was marked by considerable regional variation. The large majority of opioid prescriptions identified were for short courses of treatment with only 2.2% including two or more refills. This work is important in that the absolute incidence of opioid prescription during pregnancy is much higher in this cohort compared with that identified in earlier U.s. cohorts2,3 or scandinavian cohorts.4–6 Furthermore, the large regional variation suggests that a different balance is perceived between the value of treating the mother with a short course of opioid and potential risk to the fetus. to enhance the awareness of pain treatment among healthcare professionals, the American Pain society promoted pain as the “fifth vital sign” in the latter half of the 1990s. The Veterans health Administration (1999) and the Joint Commission on Accreditation of healthcare organizations (2000) subsequently adopted the “Pain as the fifth Vital sign” initiative to establish standards for the routine screening, assessment, and documentation of a management plan for pain. in part, as a result of these campaigns designed to combat under treatment of chronic pain, U.s. opioid prescription has greatly increased over the periods covered by the above studies, even between the period considered by the National Birth Defects Prevention study (1997 to 2005) and the current trial (2005 to 2011).7 The potential impact of liberalization of opioid prescription on the fetus is certainly worthy of consideration and has been the subject of many studies. since the rise of heroin use in the 1950s, the consequences of fetal opioid exposure have been documented for decades. opioid use during pregnancy was associated with an excess of premature delivery, low–birth-weight infants, neonatal withdrawal, and birth defects.8 however, the interpretation of these findings from small observational trials is complicated by the strong association of adverse social circumstances associated with illicit opioid use including comorbid disease and other drug use and poor maternal nutrition. Pregnant women who are prescribed a short course of opioids are less likely to be exposed to the above conditions. The risk of short-term exposure to prescription opioids to the fetus under medical supervision is more difficult to assess and needs to be carefully examined in future studies. Most studies focus on exposure in early pregnancy during the period of organogenesis although pathology may occur through more subtle changes in neuronal structure or function. An early U.s. cohort from the Collaborative Perinatal Project documenting use of propoxyphene and codeine (1959 to 1965),2 a study from a swedish birth registry identifying use of dextropropoxyphene and codeine (1985 to 1989),4 and a study based on the Norwegian Mother and Child Cohort that identified codeine (1967 to 2008)5 did not find an association between opioid prescription and congenital malformation. in contrast, several case control studies, most notably the U.s. National Birth Defects Prevention study (1997 to 2005),3 have found Balance in Opioid Prescription during Pregnancy