Treatment for Opioid Use Disorder Before, During, and After Pregnancy
Creating a treatment plan for opioid use disorder (OUD), that may include a medication for OUD such as methadone or buprenorphine, before pregnancy can help increase the chances of a healthy pregnancy.
Clinical guidance for pregnant people with OUD is available from the American College of Obstetricians and Gynecologists (ACOG) and the Substance Abuse and Mental Health Services Administration (SAMHSA). 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 people with OUD include 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.
Methadone and buprenorphine are first-line therapy options for pregnant people with OUD. ACOG and SAMHSA recommend treatment with methadone or buprenorphine for pregnant people with OUD, in conjunction with behavioral therapy and medical services. While some treatment centers use naltrexone to treat OUD in pregnant people, 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 people with OUD should be encouraged to start treatment with methadone or buprenorphine. 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 and people who are pregnant with OUD to work together to manage medical care during pregnancy and after delivery. Coordination of care between a prenatal care provider and a specialist with expertise in opioid use is important for pregnant people with OUD.
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 people who used opioids during pregnancy are monitored for NAS and receive appropriate treatment, as well as be referred to needed services.
Talk with your healthcare provider to learn more about treatment options for OUD during pregnancy. If you or someone close to you needs help for a substance use disorder, talk to a healthcare provider or call SAMHSA’s National Helpline at 1-800-662-HELP (4357).
Treatment for an Infant Affected by Neonatal Abstinence Syndrome (NAS), including Neonatal Opioid Withdrawal Syndrome (NOWS)
AAP’s Clinical Report, Neonatal Opioid Withdrawal Syndrome (NOWS), provides guidelines for managing the care of infants with long-term opioid exposure during pregnancy.
Treatment for NAS depends on many factors:
- The opioids or other medicines the newborn was exposed to during pregnancy;
- The newborn’s overall health; and
- Whether the infant was born full-term (after 37 weeks of pregnancy).
When signs of NOWS are first identified, care that involves and supports the mother is very important. The infant may need treatment with medication if there is no improvement or if the infant develops severe withdrawal.
Other strategies for managing NAS include:
- 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 NAS with the Use of Medication
NAS conditions result from newborns’ withdrawal from certain substances that they were exposed to before birth. NOWS is a subset of NAS and is specific to opioid withdrawal during the first 28 days of life.
Some babies, especially those with more severe withdrawal signs, may need medications, such as liquid oral morphine or liquid oral methadone, in addition to the other care strategies listed above that do not include the use of medicines (SAHMSA’s Factsheet 10). Medicines can help prevent seizures, improve feeding, stop diarrhea, decrease agitation, and control other severe symptoms. Once the signs of withdrawal seem to be controlled, the dosage of medication is gradually decreased. Babies being treated for NAS with medicines may need to stay longer in the hospital after birth.
Breastfeeding
In general, breastfeeding is encouraged for newborns with NAS. However, sometimes breastfeeding is not recommended. For example, breastfeeding is not recommended if mothers are using illicit drugs, are using more than one drug, or are HIV-positive. For more information, read Neonatal Opioid Withdrawal Syndrome (NOWS) and Clinical Guidance for Treating Pregnant and Parenting Women with Opioid Use Disorder and their Infants
After Hospital Discharge
The discharge plan for infants treated for NAS 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 NAS and are available to the family immediately after discharge. The American Academy of Pediatrics recommends this simple checklist to help with discharge planning and proper care 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. The Plan of Safe Care is individually designed to address the needs for each infant, caregiver, and family. Examples include substance use treatment and available services and support to meet health and developmental needs. Plans can identify agencies within the community that provide services. Plans can also help guide communication and coordination.
Treatment for People with Opioid Use Disorder After Delivery
Support for people with OUD is important after the baby is born. People 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 ACOG and SAMHSA, people with OUD should continue MOUD as prescribed after the baby is born. Healthcare providers should monitor people 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 opioid relapse occurs. People can safely continue MOUD for as long as they need it. For some, this may be months or years, and for others, it may be a lifetime.
The new AAP PediaLink course, Recovery-Friendly Care for Families Affected by Opioid Use Disorder, focuses on the care of infants and families after discharge from the birthing hospital and through the child’s third birthday. This free course discusses practical approaches for continuous, comprehensive care for children and families, designed to support the recovery goals for the parent-infant dyad.
