What is the protocol for inpatient detoxification in pregnant patients?

From the Guidelines

Pregnant women with opioid use disorder (OUD) should be maintained on medication-assisted treatment (MAT) throughout pregnancy, rather than undergoing detoxification, to minimize risks of relapse and associated harms to both mother and fetus. This approach is supported by recent evidence from the American Journal of Obstetrics and Gynecology 1, which emphasizes the importance of MAT in reducing adverse pregnancy outcomes and promoting fetal well-being.

Key Considerations for OUD Management in Pregnancy

• MAT should be continued throughout pregnancy to suppress symptoms of cravings and withdrawal, and prevent illicit opioid use 1
• Acute detoxification or attempting to wean or stop opioids before delivery is not recommended for most women, due to the risk of acute maternal withdrawal and relapse 1
• For women who are taking chronic opioids for pain, a slow titration toward a lower dosage of systemic opioids over the course of the pregnancy may be considered, under the guidance of a pain specialist 1
• An interdisciplinary approach involving the obstetric team and the addiction medicine team or methadone clinic providers is essential for ensuring comprehensive care and minimizing risks 1

Detoxification Protocols

While MAT is the preferred approach, some women may still require detoxification. In such cases, methadone maintenance is recommended, starting at 20-30mg daily and titrating by 5-10mg increments to control withdrawal symptoms. Buprenorphine (starting at 2-4mg, increasing to 16-24mg daily) is an alternative with potentially fewer neonatal complications 1. Detoxification should occur in a specialized setting with continuous fetal monitoring after 24 weeks gestation, and include comprehensive prenatal care, nutritional support, and psychosocial interventions.

Importance of Behavioral Support

Behavioral health management is mandatory throughout the detoxification process, and should continue for at least 6 months after delivery 1. Research suggests that ongoing psychologic support during the detoxification process is linked to improved outcomes for both the pregnant woman and neonate, including lower rates of neonatal abstinence syndrome (NOWS) 1.

From the FDA Drug Label

Methadone has been detected in amniotic fluid and cord plasma at concentrations proportional to maternal plasma and in newborn urine at lower concentrations than corresponding maternal urine A retrospective series of 101 pregnant, opiate-dependent women who underwent inpatient opiate detoxification with methadone did not demonstrate any increased risk of miscarriage in the 2nd trimester or premature delivery in the 3rd trimester Methadone should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

The protocol for pregnant inpatient detox with methadone is not fully established, but available data suggest that methadone can be used in pregnant women as part of a supervised therapeutic regimen. Key considerations include:

• Risk of miscarriage: No increased risk in the 2nd trimester
• Risk of premature delivery: No increased risk in the 3rd trimester
• Fetal growth: Decreased fetal growth with reduced birth weight, length, and/or head circumference
• Neonatal withdrawal: Babies born to mothers taking opioids may be physically dependent, with withdrawal symptoms usually appearing in the first days after birth 2

From the Research

Protocol for Pregnant Inpatient Detox

There are limited studies specifically focused on the protocol for pregnant inpatient detox. However, the available evidence provides some insights into the effectiveness of different medications and treatment approaches for opioid detoxification, which can be relevant to pregnant patients.

• The study by 3 found that buprenorphine was significantly superior to clonidine and lefetamine in controlling objective, subjective, and psychological withdrawal symptomatology in methadone maintenance patients.
• The study by 4 compared the effectiveness of different doses of sublingual buprenorphine and clonidine in opioid detoxification and found that both low and high doses of buprenorphine and clonidine were comparable in controlling withdrawal.
• The study by 5 recommended a treatment approach for opioid detoxification and naltrexone induction, which included using an initial 2-4 mg dose of buprenorphine combined with clonidine, other ancillary medications, and progressively increasing doses of oral naltrexone over 3-5 days.
• The study by 6 compared the efficacy of methadone, buprenorphine, clonidine, and lofexidine for opioid detoxification and found that buprenorphine and methadone were ranked as the most effective methods of opioid detoxification.

Considerations for Pregnant Patients

While the above studies do not specifically focus on pregnant patients, the study by 7 highlights the importance of integrated care for pregnant and parenting people with substance use, including knowledge about specific substances used, treatment options, and an integrated, trauma-informed care team.

• The study by 7 emphasizes the need for evidence-based practice for screening, intervention, and ongoing support for pregnant people and their families impacted by substance use.
• However, there is a lack of specific research on the protocol for pregnant inpatient detox, and more studies are needed to provide guidance on the best treatment approaches for this population.