Page 254 Guide to Pain Management in Low-Resource Settings

242 Author(s)

being used by patients illicitly). If prolonged admin- a quiet environment, and some will need treatment with
istration is expected, drugs without active metabo- sedative drugs such as phenobarbitone (10 mg/day), di-
lites are preferable, for example methadone rather azepam, clonidine, or morphine (starting at 0.4–1.0 mg/
than morphine for maintenance therapy in opioid ad- day in divided doses and increasing 10–20% every 2–3
dicts. Although there is a slightly higher rate of low days as needed). Treatment may need to be continued
birth weight and stillbirth among women on chronic for 4–20 days and sometimes much longer.
opioid therapy, the majority have good neonatal out-
comes. It has been suggested that chronic opioid use Pearls of wisdom
in pregnancy is associated with addictive behavior in
later adult life, but observational evidence does not • Know which common analgesics are considered
prove causality, and such findings should be viewed safe in early pregnancy, and know where to fi nd
with some scepticism. Women who become opi- an information resource describing drug safety
oid tolerant and need escalating doses will provide a in pregnancy and lactation. Be guided by pub-
number of challenges in managing pain during labor, lished recommendations and liaise with other
as well as during and after cesarean section. Options medical and nursing staff involved in pain man-
such as opioid rotation and multiple opioids may agement.
need to be considered (see chapter on chronic opioid • Choose a postoperative analgesic regimen af-
therapy). These women need more interventions and ter cesarean section that is not only eff ective but
increase the staff workload. also minimizes neonatal drug exposure through
The neonatal effects of opioid analgesics be- breast milk. Th ere should be a multimodal opi-
ing used at the time of childbirth are important, so oid-based approach, preferably using the spinal
a number of staff need to be aware of opioid con- (subarachnoid) route of opioid administration. If
sumption, including the obstetrician, midwife, pe- a systemic opioid is used it should be combined
diatrician, and local doctor. Neonatal respiratory de- with nonopioid analgesics and/or a regional an-
pression may be present at birth, so staff skilled in algesic method (e.g., the transversus abdominis
neonatal resuscitation may be required; if possible, plane block).
naloxone should be available. Also, the baby should • Use of opioids during pregnancy does not cause
be observed in a high-dependency care area if possi- fetal malformations but may result in neonatal re-
ble, and staff trained to watch for neonatal withdraw- spiratory depression at birth and a neonatal absti-
al/neonatal abstinence syndrome. This syndrome nence syndrome starting the fi rst or second day
usually commences in the hours or days following after birth.
birth (depending on the half-life of the specific opi- • During and immediately after pregnancy,
oid, i.e., 6–36 hours for morphine and 24–72 hours paracetamol (acetaminophen) is the safest nono-
for methadone and buprenorphine), but it is occa- pioid analgesic, and opioids other than codeine
sionally delayed for several days. The risk is greatest and pethidine are preferred.
if the mother has become opioid-tolerant and has • Nonsteroidal anti-infl ammatory drugs are valu-
needed an escalation dose or high maintenance doses able analgesics but should be reserved for use
(30–90% incidence with long-term methadone use during the second trimester of pregnancy and
and 50% incidence, but less severe, with buprenor- must be avoided after 32 weeks’ gestation.
phine maintenance therapy). Unfortunately, breast- • Use the following table to make an individual
feeding does not prevent the syndrome. The signs risk-benefi t-ratio for your patient before starting
and symptoms in the baby are due to autonomic analgesia:
overactivity (which can manifest as yawning, sneez-
ing, or fever) and cerebral irritability (for example
tachypnea, tremor, increased tone, poor feeding be-
havior, and in severe cases, seizures). The severity of
the syndrome also correlates partly with the maternal
dose, so is most severe in opioid-tolerant or addicted
women. The baby should be swaddled and nursed in