American Academy of Nursing

View all recommendations from this society

Released June 12, 2016

Don’t prescribe opioid pain medication in pregnancy without discussing and fully weighing the risks to the woman and her fetus.

In utero exposure to opioids can lead to risks for the infant, including neonatal abstinence syndrome (NAS) and/or developmental deficits affecting behavior and cognition.

Pregnant women’s use of opioids dramatically increased from 1.19 per 1000 hospital births in 2000 to 5.63 per 1000 hospital births in 2009. Prescription opioids are among the most effective medications for the treatment of pain. However, regular or long-term use of opioids can create physical dependence and in some cases, addiction. Women who are prescribed, or continue to use, opioids during pregnancy may not understand the risks to themselves or their babies.

Pregnant women and their fetuses are an inherently vulnerable population and opioid dependence increases their vulnerability. Women using opioids during pregnancy were shown to have higher rates of depression, anxiety and chronic medical conditions as well as increased risks for preterm labor, poor fetal growth and stillbirth.

Women who used opioids during pregnancy were four times as likely to have a prolonged hospital stay compared to nonusers and incurred signifi more per-hospitalization cost.

Neonatal abstinence syndrome (NAS) occurs in newborns that are exposed to substances, typically opioids, while in their mothers’ wombs. In utero exposure to these substances can cause a newborn to experience withdrawal symptoms after birth. Symptoms of NAS vary depending on the type and amount of the substance that the mother used, how the mother and fetus metabolize the drug and how long the mother used the drug. Symptoms of NAS range from blotchy skin and sneezing, to respiratory complications, low birth weight, prematurity, feeding difficulties, extreme irritability and seizures.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a health professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician or nurse.

How The List Was Created

The American Academy of Nursing has convened a Task Force of member fellows who are leaders of professional nursing organizations representing a broad range of clinical expertise, practice settings and patient populations. The Task Force collaboratively identifies nursing/interdisciplinary interventions commonly used in clinical practice that do not contribute to improved patient outcomes or provide high value. An extensive literature search and review of practice guidelines is conducted for each new proposed recommendation for the list. The supporting evidence is then reviewed by the respective nursing organization(s) with the most relevant expertise to each recommendation. The Academy Task Force narrows the recommendations through consensus, based on established criteria. The final recommendations are presented to the American Academy of Nursing’s Board of Directors for approval to be added to the Choosing Wisely list created by the Academy. Once approved by the Academy’s Board of Directors, the recommended statements are sent to the ABIM Foundation for an external review by physician(s) and nurse(s) and final approval for consistency with the ABIM Foundation principles.

Recommendations were developed in partnership with the following organizations: Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), recommendations 1, 11, 12, & 13; Academy’s Expert Panel on Aging, recommendations 2, 3, 14, 15, & 24; American Association of Critical- Care Nurses (AACN), recommendations 4 & 5; Oncology Nursing Society (ONS), recommendations 6, 7, 8, 9, & 10; American Association of Neuroscience Nurses (AANN), recommendations 16, 17, 18, 19, & 20; Academy’s Expert Panel on Acute & Critical Care, recommendation 21; Society of Pediatric Nurses (SPN), recommendation 22; American Pediatric Surgical Nurses Association, Inc. (APSNA), and the American Pediatric Surgical Association (APSA), recommendation 23; and the Association of periOperative Registered Nurses (AORN), American Association of Nurse Anesthetists (AANA), and the American Association of Neuroscience Nurses (AANN), recommendation 25.

The American Academy of Nursing’s conflict of interests and disclosures policy can be found at


Opioid abuse, dependence, and addiction in pregnancy. ACOG committee opinion number 524. Washington (DC): American College of Obstetricians and Gynecologists. 2012 May. Available from: and-Addiction-in-Pregnancy.

Criminalization of pregnant women with substance use disorders. J Obstet Gynecol Neonatal Nurs. 2015 Jan-Feb; 44(1), 155–7.

Medication use in pregnancy: a public health concern. Atlanta (GA): Centers for Disease Control and Prevention. 2015 Jan 16 [cited 2016 May 15]. Available from:

Opioid painkillers widely prescribed among reproductive age women. Atlanta (GA): Centers for Disease Control and Prevention. 2015 Jan 22 [cited 2016 May 22]. Available from:

Patrick SW, Schumacher RE, Benneyworth BD, Krans EE, McAllister JM, Davis MM. Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009. JAMA. 2012 May 9;307(18):1934-40.

Addressing prescription drug abuse in the United States: current activities and future opportunities. Washington (DC): Department of Health and Human Services. 2013 Sep. 36 p. Volkow ND. Prescription opioid and heroin use. Bethesda (MD): National Institute on Drug Abuse. 2014 Apr.

Whiteman VE, Salemi JL, Mogos MF, Cain MA, Aliyu MH, Salihu HM. Maternal opioid drug use during pregnancy and its impact on perinatal morbidity, mortality, and the costs of medical care in the United States. J Pregnancy. 2014:906723.