Peripartum anesthetic management for patients who are opioid tolerant or with OUD

	Vaginal delivery	Cesarean delivery
Chronic opioid use (ie, OUD on MAT, OUD untreated, or taking opioids for chronic pain)	Labor analgesia: Continue regularly scheduled opioid Neuraxial labor analgesia preferred If neuraxial analgesia is not possible, IV PCA Avoid nitrous oxide; use with opioids can lead to respiratory depression Avoid mixed agonist/antagonist medications (eg, nalbuphine, pentazocine, butorphanol) due to risk of withdrawal Postpartum analgesia: Regularly scheduled acetaminophen and NSAIDs For patients with third or fourth degree vaginal lacerations, consider neuraxial long-acting opioid (ie, preservative free morphine or hydromorphone)	Anesthesia: Neuraxial anesthesia preferred Anticipate need for nonpharmacologic support +/– sedatives during procedure Post cesarean analgesia: Regularly scheduled acetaminophen and NSAIDs. For patients who have neuraxial anesthesia: Neuraxial long acting opioids (ie, preservative free morphine or hydromorphone) For patients who have general anesthesia and for rescue analgesia: TAP or QL blocks, PCA, local anesthetic wound infiltration catheter, or continuous epidural analgesia
Patients with OUD now abstinent	Labor analgesia: Neuraxial labor analgesia preferred If neuraxial analgesia is not possible: nitrous oxide Postpartum analgesia: Regularly scheduled acetaminophen and NSAIDs For patients with third or fourth degree vaginal lacerations, consider neuraxial long-acting opioid (ie, preservative free morphine or hydromorphone)	Anesthesia: Neuraxial anesthesia preferred Post cesarean analgesia: Regularly scheduled acetaminophen and NSAIDs. For patients who have neuraxial anesthesia: Neuraxial long acting opioids (ie, preservative free morphine or hydromorphone) For patients who have general anesthesia and for rescue analgesia: TAP or QL blocks, local anesthetic wound infiltration catheter and/or continuous epidural analgesia
Patients with OUD now abstinent, taking naltrexone	Labor analgesia: Neuraxial labor analgesia with local anesthetic only without opioids preferred Avoid systemic opioids If neuraxial analgesia is not possible, nitrous oxide is an option Postpartum analgesia: Regularly scheduled acetaminophen and NSAIDs	Anesthesia: Neuraxial anesthesia preferred, local anesthetic only without opioids Post cesarean analgesia: Regularly scheduled acetaminophen and NSAIDs. TAP or QL blocks, or continuous epidural analgesia with local anesthetic, or local anesthetic wound infiltration/catheter Avoid reliance on neuraxial or systemic opioids*

This table shows an approach to peripartum management of patients with OUD or who chronically use opioids for pain.

OUD: opioid use disorder; MAT: medication-assisted therapy; IV: intravenous; PCA: patient-controlled analgesia; NSAIDs: nonsteroidal antiinflammatory drugs; TAP: transversus abdominis plane; QL: quadratus lumborum.
* The efficacy of opioids may be unpredictable, depending on the timing since the last dose of oral naltrexone. If naltrexone is still in effect (ie, within 48 to 72 hours of the last oral dose, or patients with a naltrexone implant in place), opioids will probably be ineffective. If naltrexone has been held for more than 48 to 72 hours, the patient may be more sensitive to opioids, and may be at risk for respiratory depression.

Graphic 132055 Version 1.0

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Peripartum anesthetic management for patients who are opioid tolerant or with OUD