Presented September 3, 2025 at the 2025 APSF Stoelting Conference on “Transforming Maternal Care: Innovations and Collaborations to Reduce Morbidity and Mortality”
SUMMARY
Brinda Kamdar, MD’s presentation highlights the critical need for evidence-based and compassionate care in managing Opioid Use Disorder (OUD) in pregnancy, noting its dramatic escalation and severe impact on maternal and fetal health. The standard of care is Medication for OUD (MOUD), primarily methadone or buprenorphine, to prevent dangerous withdrawal and reduce overdose risk. The presentation strongly emphasizes the imperative to dismantle pervasive healthcare stigma and bias, which often leads to patient avoidance of care, advocating for a patient-centered approach that prioritizes psychological safety, empowerment, and non-judgmental communication.
Key Points:
- Increased Maternal and Fetal Risk
OUD in pregnancy is associated with significantly increased odds of adverse maternal outcomes, including 2x higher odds of pre-term labor, placental abruption, and 4x higher odds of in-hospital mortality. Fetal risks include increased odds of Intrauterine Growth Restriction (IUGR) and stillbirth [03:06, 03:57]. - MOUD is Standard of Care
Medication for OUD (MOUD) with methadone or buprenorphine is the evidence-based standard of care. It is associated with a significantly lower rate of fatal and non-fatal overdose compared to no pharmacotherapy [06:06, 13:23]. The highest risk for overdose occurs postpartum (7 to 12 months), underscoring the need for continued services [13:40]. - Buprenorphine Benefits
Evidence suggests buprenorphine is associated with a lower risk of adverse neonatal outcomes (e.g., Neonatal Abstinence Syndrome, pre-term birth, small for gestational age) compared to methadone, though both are appropriate for continued use if the patient is stable [08:33]. - Avoid Opioid Withdrawal
Repeated episodes of opioid withdrawal are extremely taxing to maternal and fetal physiology. Maternal withdrawal causes catecholamine release, vasoconstriction, increased uterine contractility, and decreased placental blood flow, significantly increasing morbidity and mortality [04:43, 05:03]. - MOUD Dosing in Pregnancy
Due to increased clearance, most patients require an increase in their dose and often split dosing of their MOUD (methadone or buprenorphine) during the third trimester to prevent withdrawal symptoms [10:08, 10:24]. - Addressing Stigma and Bias
Healthcare discrimination is pervasive, and racial disparities exist, with Black women less likely to receive MOUD and often receiving lower doses [12:14, 12:31]. Providers must use non-stigmatizing language (e.g., “substance use disorder” instead of “addict,” “clean/dirty”) and use a functional pain scale (focused on ability to perform tasks) to improve patient-provider trust and engagement [17:38, 21:13].
ABOUT THE SPEAKER(S)
Brinda Kamdar, MD
Assistant Professor of Anesthesiology,
Harvard Medical School
Program Director for the Regional Anesthesiology,
Massachusetts General Hospital (MGH)
Brinda Bharat Kamdar is an Assistant Professor of Anesthesiology at Harvard Medical School, where she serves as Program Director for the Regional Anesthesiology at Massachusetts General Hospital (MGH). She serves as an associate editor for the Regional Anesthesia & Pain Medicine journal, and has been recognized for mentorship of faculty as the recipient of the MGH Faculty Clinical Mentorship Award in 2017 and 2022. Particular areas of interest are real-time lumbar and thoracic neuraxial ultrasound, a topic she has given multiple invited lectures including at SOAP and ASRA meetings as well as pain management in obstetric patients with opioid use disorder, an evolving specialty in which she has developed significant expertise. In addition, she is an extremely passionate teacher at MGH, being selected as the Honorary Keynote speaker to deliver the Class of 2024 MGH Anesthesia Department Commencement Address, as well as more recently as the 2025 SOAP Teacher of the Year and 2025 ASRA Excellence in Education Award recipient.
