P011: TRANSLATING GUIDELINES INTO PRACTICE: LABOR ANALGESIA IN PATIENTS WITH OUD
Sanjana Kota; Mariana Acosta, MD; Gretel Carmenate, MD; Adriana Grossman, MD
University of Miami, Miller School of Medicine
Introduction: The prevalence of opioid use disorder (OUD) in pregnancy continues to rise, yet peripartum pain management in this population remains challenging due to opioid tolerance, opioid-induced hyperalgesia, relapse risk, and coexisting psychiatric and polysubstance comorbidities. Multiple studies have demonstrated that pregnant patients with OUD have higher rates of depression and anxiety and are at increased risk for concurrent substance use. These factors are independently associated with increased pain and higher analgesic requirements. As the clinical burden of these patients grows, evidence-based guidance for peripartum pain management remains limited and implementation in day-to-day labor and delivery practice variable. We present a case demonstrating successful application of current guideline recommendations for labor analgesia in a patient with untreated OUD and polysubstance use.
Methods: We reviewed published guidelines and literature addressing peripartum pain management in pregnant patients with OUD. We synthesized recommendations regarding prenatal anesthesiology consultation, management of medications for OUD (MOUD), neuraxial labor analgesia, avoidance of systemic opioids, and multidisciplinary care coordination. We retrospectively analyzed a clinical case of a parturient with untreated OUD and polysubstance use managed with neuraxial analgesia, evaluating adherence to guideline recommendations and clinical outcomes.
Results: We present the case of a 35-year-old gravida 1 para 0 woman at 40.4 weeks gestation with untreated OUD, concurrent stimulant and tobacco use, and psychiatric comorbidities who presented for labor induction. The patient initially declined neuraxial analgesia, opting for intravenous pain-controlled analgesia (PCA). Pain remained poorly controlled despite systemic opioids. After prolonged inadequate analgesia, the patient consented to epidural placement with bupivacaine and fentanyl, resulting in marked improvement in pain control. She progressed to vacuum-assisted vaginal delivery without anesthetic complications or need for opioid escalation. The patient was referred to postpartum addiction medicine services for MOUD initiation.
This clinical course mirrors key consensus recommendations: early anesthesiology involvement, neuraxial-first analgesic strategies to minimize systemic opioid exposure, and multidisciplinary, patient-centered management in the setting of psychiatric and polysubstance comorbidity.
Discussion: This case demonstrates practical translation of evidence-based guidelines into labor and delivery practice in an increasingly complex patient population. Early anesthesiology involvement is crucial, facilitating expectation setting, shared decision-making, and coordination with obstetrics and addiction medicine, particularly in patients at risk for complex pain trajectories. The patient’s initial course illustrates the limitations of intravenous opioid–based strategies in the setting of opioid tolerance and opioid-induced hyperalgesia where analgesia may remain inadequate.
A neuraxial-first approach remains gold-standard, not only for improving analgesia but also for avoiding strategies that increase the risk of oversedation or withdrawal. Mixed opioid agonist–antagonists should be avoided because of the risk of precipitating withdrawal. Management should therefore emphasize initiation of MOUD alongside neuraxial analgesia and opioid-sparing strategies.
Postpartum care warrants equal attention. Proactive counseling regarding pain expectations, safe opioid use, and multimodal analgesia can reduce uncertainty and improve adherence, while timely transition to addiction medicine supports continuity of treatment and reduces relapse risk. This case underscores that effective peripartum management of OUD is inherently multifactorial and systems-based, requiring coordinated, multidisciplinary care beyond delivery to optimize maternal outcomes.