Treatment for Opioid Use Disorder Before, During, and After Pregnancy
If a woman is pregnant or planning to become pregnant, the first thing she should do is talk to a healthcare provider. Some women need to take an opioid medication during pregnancy to manage pain or to treat opioid use disorder (OUD). Creating a treatment plan for OUD, as well as other co-occurring health conditions, before pregnancy can help a woman increase her chances of a healthy pregnancy.
Clinical guidance for pregnant women with OUD is available from the American College of Obstetricians and Gynecologists (ACOG)external icon and the Substance Abuse and Mental Health Services Administration (SAMHSA)pdf iconexternal icon. As noted in their recommendations, quickly stopping opioids during pregnancy is not recommended, as it can have serious consequences, including preterm labor, fetal distress, or miscarriage. Current clinical recommendations for pregnant women with OUD include treatment with medication for opioid use disorder (MOUD), rather than supervised withdrawal, due to a higher likelihood of better outcomes and a reduced risk of relapse.
Medication for Opioid Use Disorder (MOUD) During Pregnancy
Medication for Opioid Use Disorder (MOUD) refers to the use of medication to treat opioid use disorder. This type of treatment can lead to more favorable outcomes.
Methadoneexternal icon and buprenorphineexternal icon are first-line therapy options for pregnant women with OUD. SAMHSA and the ACOG recommend treatment with methadone or buprenorphine for pregnant women with OUD, in conjunction with behavioral therapy and medical services. Combination pills containing both buprenorphine and naloxone are not recommended for treatment of OUD in pregnant women due to limited evidence at this time. While some treatment centers use naltrexone to treat OUD in pregnant women, current information on its safety during pregnancy is limited. ACOG recommends that if a woman is stable on naltrexone prior to pregnancy, the decision regarding whether to continue naltrexone treatment during pregnancy should involve a careful discussion between the provider and the patient, weighing the limited safety data on naltrexone with the potential risk of relapse with discontinuation of treatment.
Pregnant women with OUD should be encouraged to start treatment with methadone or buprenorphine (without naloxone). Like many medications taken during pregnancy, MOUD has unique benefits and risks to pregnant women and their babies. It is important for healthcare providers to work closely with pregnant women to manage the medical care for both mother and baby during pregnancy and after delivery. Coordination of care between an obstetrician-gynecologist (OB-GYN) and an addiction specialist is important for pregnant women with OUD. Pregnant women with OUD may also seek care from OB-GYNs and other primary care providers who have additional training on addiction treatment.
It is important to recognize that neonatal abstinence syndrome (NAS) is an expected condition that can follow exposure to MOUD. A concern for NAS alone should not deter healthcare providers from prescribing MOUD. Close collaboration with the pediatric care team can help ensure that infants born to women who used opioids during pregnancy should be monitored for NAS and treated.
Talk with your healthcare provider to learn more about treatment options for OUD during pregnancy.external icon If you or someone close to you needs help for a substance use disorder, talk to a healthcare provider or call SAMHSA’s National Helplineexternal icon at 1-800-662-HELP (4357).
Treatment for an Infant Affected by (Neonatal Opioid Withdrawal Syndrome (NOWS)
AAP’s Clinical Report, Neonatal Opioid Withdrawal Syndromeexternal icon (NOWS), provides guidelines for managing the care of infants with long-term opioid exposure in the womb.
Treatment for (NOWS) depends on many factors:
- The opioids or other medicines the newborn was exposed to in the womb;
- The newborn’s overall health; and
- Whether the infant was born full-term (between 39 and 40 weeks of pregnancy).
When signs of NOWS are first identified, care that involves and supports the mother can also serve as a basis of care for the newborn. Treatment with medication may be needed if there is no improvement or if the infant develops severe withdrawal.
Management of NOWS Without the Use of Medication
This type of care may include the following approaches:
- Placing the infant in a dark, quiet area to lessen both light and sound;
- Swaddling the infant;
- Gently rocking the infant or using other positioning or comforting methods;
- Providing frequent, small amounts of high-calorie formula or breast milk to help with feeding problems; or
- Allowing the infant to stay in the same hospital room as the mother.
Management of NOWS with the Use of Medication
NAS is a group of conditions that can occur when newborns withdraw from certain substances, including opioids, that they were exposed to before birth. Withdrawal caused by in utero exposure to opioids during the first 28 days of life is also called neonatal opioid withdrawal syndrome (NOWS).
Some babies, especially those with more severe withdrawal signs, may need medications, such as liquid oral morphine or liquid oral methadone, in addition to care without the use of medicines (SAHMSA’s Factsheet 10pdf iconexternal icon). Medicines can help prevent seizures, improve feeding, stop diarrhea, decrease agitation, and control severe symptoms. Once the signs of withdrawal seem to be controlled, the dosage of medication is gradually decreased. Babies being treated for NOWS with medicines may need to stay longer in the hospital after birth.
In general, breastfeeding is encouraged for newborns with NOWS when the mothers are responding well to MOUD. However, sometimes breastfeeding is not recommended. For example, breastfeeding is not recommended if mothers are taking drugs illegally, are using more than one drug, or are HIV-positive. For more information, read Neonatal Opioid Withdrawal Syndromeexternal icon (NOWS) and Clinical Guidance for Treating Pregnant and Parenting Women with Opioid Use Disorder and their Infantspdf iconexternal icon
After Hospital Discharge
The discharge plan for infants treated for NOWS may include home visits and services, such as parenting support and links to home nurses and social workers. The plan may also include referrals to healthcare workers who know about NOWS and are available to the family immediately after discharge. The American Academy of Pediatrics recommends this simple checklistimage iconexternal icon to help with discharge planning and proper care for mother and baby after leaving the hospital.
Plans of Safe Care
Families and caregivers with an infant treated for NAS or other prenatal substance exposure should receive a Plan of Safe Care. The goals of the plan are to strengthen the family, keep the child safe, and link the family with services in their community. This plan is individually designed for each infant and caregiver to identify and outline a plan to address the needs of the infant (for example, services and supports available to meet health and developmental needs) and the caregiver and family (for example, substance use treatment). Plans can identify agencies within the community that provide services. Plans can also help guide communication and coordination.
Treatment for Mothers with Opioid Use Disorder After Delivery
Support for women with OUD is important after the baby is born. Women may be adjusting to many new factors in their lives. For example, they may experience a lack of sleep and anxiety about the demands of caring for a newborn.
According to SAMHSA and ACOG, women with OUD should continue MOUD as prescribed after the baby is born. Healthcare providers should monitor women during this time and adjust the dosage if needed. Discontinuation of MOUD for OUD should generally be avoided in the time immediately after the baby is born. At the very least, it should be avoided until the baby is consistently sleeping through the night and has completed breastfeeding. However, ending MOUD later may be considered if the mother is stable, if the mother and child are well-bonded, if the mother and child have a safe and stable home and social environment, and only with medical supervision and when it is in the best interest of the mother and child.
Plans to stop MOUD should be made together with the healthcare team. MOUD must be reduced slowly to prevent withdrawal. A safety plan for the mother and family needs to be in place before slowly stopping MOUD, so that plans are in place if she relapses to opioid use. People can safely continue MOUD for as long as they need it. For some, this may be months or a year; for others, it may be a lifetime.
Screening for Other Mental Health Conditions
Women with OUD may also have other mental health conditions, including depression and anxiety. They should receive recommended screening for depression and other mental health conditions. Access to appropriate psychosocial support should be made available.