Special Populations — Pregnancy, Adolescents, Geriatric
Module 8 of 11 · 45 min
OUD in pregnancy (MAT preferred over withdrawal), adolescent SUD, geriatric polypharmacy + pain.
Learning objectives
- •Manage OUD in pregnancy per ACOG/SAMHSA
- •Recognize adolescent substance use patterns + screen appropriately
- •Address geriatric pain + medication-related risks
- •Avoid common pitfalls in special-population prescribing
OUD in pregnancy
MAT (buprenorphine OR methadone) is the standard of care — better outcomes than withdrawal/detox (which has high relapse rate + risks fetal distress). Buprenorphine: less neonatal abstinence syndrome (NAS) severity than methadone; subutex (without naloxone) historically used in pregnancy though emerging evidence shows suboxone is safe too. Methadone: longer track record; titrate doses up as plasma volume expands in 3rd trimester. NAS expected in ~50% of MAT-exposed neonates; treated with finnegan-scoring + supportive care + morphine if severe.
Adolescents
Brain still developing → earlier substance exposure = higher lifetime SUD risk. SBIRT (Screening, Brief Intervention, Referral to Treatment) recommended. Use CRAFFT screen: Car, Relax, Alone, Forget, Family/Friends, Trouble. ≥ 2 = positive. Avoid prescribing opioids if at all possible — pediatric tonsillectomy is exception (alternatives often inadequate). Buprenorphine FDA-approved 16+; off-label younger. Engage parents AND respect adolescent autonomy in confidentiality conversations.
Geriatric pain + polypharmacy
Elderly: smaller volume of distribution, slower clearance, more sensitivity to opioids → start at HALF normal dose, titrate slow. Avoid: meperidine (active metabolite seizures), pentazocine (delirium), propoxyphene (cardiotoxicity). Beers Criteria flags problem opioids. Falls risk: opioids + benzos + sleep aids = falls + hip fractures. Multimodal first: acetaminophen scheduled, topicals (lidocaine, diclofenac), PT. NSAIDs more cautious (renal, GI, CV).
Psychiatric comorbidity in any population
Depression + chronic pain = bidirectional. Treating depression often improves pain. SNRIs (duloxetine, venlafaxine) work for both. Avoid benzodiazepines for chronic anxiety + pain (additive opioid risk + fall risk). Refer to behavioral health.
References
- · ACOG OUD in Pregnancy
- · AAP Adolescent Substance Use
- · Beers Criteria 2023