Opioid Use and Pregnancy

Pregnant, postpartum, and parenting persons should receive compassionate, evidence-based care for pain or opioid use disorder (OUD). The American College of Obstetricians and Gynecologists (ACOG) recommends balancing a cautious approach to prescribing opioids with the need to address pain, while also emphasizing that pregnancy should not be a reason to avoid treating acute pain.¹ The 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain (2022 CDC Clinical Practice Guideline) provides in-depth recommendations for safer and effective pain management, including during and after pregnancy.

Pain Management for Pregnant Individuals or Individuals Who May Become Pregnant

Before initiating opioid therapy for someone who can become pregnant, clinicians and their patients should discuss potential effects of long-term opioid use on any future pregnancy. For all people with reproductive potential, it is important to discuss future pregnancy intentions and engage in shared decision-making regarding contraception, if appropriate.

Clinicians and patients together should carefully weigh benefits and risks when making decisions about whether to initiate opioid therapy for pain during pregnancy (see Recommendation 8).

Acute Pain
When opioids are needed for treatment of acute pain in pregnant people:

• The lowest effective dose should be used (see also Recommendation 4).

• The treatment should not be longer than the expected duration of pain severe enough to require opioids (see also Recommendation 6).

Chronic Pain
For pregnant people with chronic pain, ACOG recommends avoiding or minimizing the use of opioids for pain management, and highlights alternative pain therapies such as:

• Nonpharmacologic treatments (e.g., exercise, physical therapy, behavioral approaches).
• Nonopioid pharmacologic treatments.

Tapering Opioids

Clinicians should consult with appropriate expertise in pain management or addiction medicine for pregnant persons if considering tapering opioids during pregnancy because of possible risks to the pregnant patient and to the fetus if the patient goes into withdrawal (see Recommendation 5).

Pain Management for Postpartum Individuals

For pain management in the postpartum period, ACOG recommends stepwise, multimodal, shared decision-making, incorporating pharmacologic treatments that might include opioids.²

• Vaginal delivery: ACOG recommends acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs), and if needed, adding an opioid.
• Cesarean delivery: ACOG recommends standard oral and parenteral medications such as acetaminophen, NSAIDs, or low-dose, low-potency, short-acting opioids with duration of opioid use limited to the shortest reasonable course expected for treating acute pain.

ACOG recommends counseling people who are prescribed opioids about the risk of central nervous system depression in the postpartum person and in the breastfed infant. If a codeine-containing medication is selected for treatment of pain, duration of therapy and neonatal signs of toxicity should be reviewed with patients and their families.

Treating OUD in Pregnant and Postpartum Individuals

OUD Treatment During Pregnancy

Early universal screening, brief intervention (e.g., engaging in a short conversation, providing feedback and advice), and referral for treatment of pregnant people with OUD improve both maternal and infant outcomes.

• For pregnant people with OUD, medications for opioid disorder (MOUD) is preferred over withdrawal management (i.e., discontinuation of opioids through either short- or medium-term tapering).
• MOUD (buprenorphine or methadone) is the recommended therapy and should be offered as early as possible in pregnancy to prevent harms to both the patient and the fetus (see also Recommendation 12).
  • Keep in mind, changes occur in a pregnant person’s body that may require dose adjustments, especially in the third trimester.

OUD Treatment After Pregnancy

According to SAMHSA and ACOG MOUD should be continued postpartum for individuals with OUD. The postpartum period is a time of increased vulnerabilities, as the demands of caring for the new baby, sleep deprivation, and threat of loss of child custody are potential triggers for return to use.³

Depression, anxiety, bipolar disorder, and posttraumatic stress disorder are more common among women with OUD.

• Screening for postpartum depression should be routine, and assessing for other co-occurring mental health conditions should be considered if there is a prior history or if concern exists.
• Additional caution and increased monitoring might lessen the increased risk for overdose among patients with depression (see Recommendation 7).

For more information about the treatment of pregnant and postpartum individuals with OUD, please visit ACOG—Opioid Use and Opioid Use Disorder in Pregnancy and Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants.

Breastfeeding During Treatment for OUD

For people receiving buprenorphine or methadone for OUD, the American Academy of Pediatrics (AAP) recommends the following:

• Breastfeeding be supported if there has been no return to drug use for 90 or more days and there are no other contraindications.
• Breastfeeding be considered if there has been no return to drug use within 30 to 90 days.
• Breastfeeding be discouraged if there is active substance use or has been a return to drug use within the last 30 days.

For more information, read the AAP’s Clinical Report, Neonatal Opioid Withdrawal Syndrome, and Clinical Guidance for Treating Pregnant and Parenting Women with Opioid Use Disorder and their Infants.

Newborn Monitoring After Delivery

Clinicians caring for pregnant people taking prescribed or nonprescribed opioids should arrange for delivery (i.e., childbirth) at a facility prepared to monitor, evaluate for, and treat neonatal opioid withdrawal syndrome. In instances when travel to such a facility would present an undue burden on the pregnant person, it is appropriate for the clinician to arrange to deliver locally, monitor and evaluate the newborn for neonatal opioid withdrawal syndrome, and transfer the newborn for additional treatment as needed. Comprehensive coordinated care including the pediatrician, mental health specialists, and other hospital supports (e.g., social work and home-nurse visitation programs) is important to appropriately assess and assist families for the critical transition from the hospital or treatment facility to home after birth.⁴