From the Guidelines
The recommended approach for managing opiate withdrawal in pregnancy is medication-assisted treatment (MAT) with either methadone or buprenorphine, rather than abrupt discontinuation or detoxification. This approach is supported by recent evidence, including a study published in the American Journal of Obstetrics and Gynecology in 2019 1, which recommends the continuation of buprenorphine with naloxone for women experiencing opioid withdrawal during pregnancy.
Key Considerations for MAT
- Methadone is typically started at 20-30mg daily and titrated to a maintenance dose of 60-120mg daily, while buprenorphine is initiated at 2-4mg and increased to 8-24mg daily 1.
- These medications should be continued throughout pregnancy and postpartum, with patients requiring comprehensive prenatal care, including frequent monitoring, screening for other substance use, and psychosocial support.
- Abrupt withdrawal is strongly discouraged as it can cause fetal distress, preterm labor, and increases the risk of relapse.
- MAT improves pregnancy outcomes by stabilizing maternal opioid levels, reducing illicit drug use, and preventing withdrawal symptoms that could compromise placental blood flow.
Benefits of Buprenorphine
- Buprenorphine has been shown to have some advantages over methadone, including shorter hospital stays and treatment durations for neonatal abstinence syndrome, as well as lower cumulative doses of morphine required for treatment 1.
- Ideal candidates for treatment with buprenorphine include those with a history of good past response to buprenorphine, availability of a buprenorphine prescriber, and an inadequate response to methadone.
Coordination of Care
- Treatment should be coordinated between obstetric providers, addiction specialists, and pediatricians to ensure optimal care for both mother and baby.
- A multidisciplinary approach to care, including counseling and social support, is essential for improving outcomes for women with opioid use disorder during pregnancy.
From the FDA Drug Label
Use of opioid analgesics for an extended period of time during pregnancy may cause neonatal opioid withdrawal syndrome Neonatal opioid withdrawal syndrome presents as irritability, hyperactivity and abnormal sleep pattern, high pitched cry, tremor, vomiting, diarrhea, and/or failure to gain weight. The duration and severity of neonatal opioid withdrawal syndrome may vary Observe newborns for signs of neonatal opioid withdrawal syndrome and manage accordingly
The recommended approach for managing opiate withdrawal in pregnancy is not explicitly stated in the provided drug label. However, it is mentioned that neonatal opioid withdrawal syndrome can occur in newborns whose mothers used opioid analgesics during pregnancy. It is advised to closely monitor neonates for signs of respiratory depression and manage accordingly. An opioid antagonist such as naloxone should be available for reversal of opioid-induced respiratory depression in the neonate 2.
From the Research
Managing Opiate Withdrawal in Pregnancy
The recommended approach for managing opiate withdrawal in pregnancy involves medication-assisted treatment, with opioid agonist therapy being the standard of care 3, 4, 5. This approach is preferred over medication-assisted withdrawal, as it produces the best outcome for women and their children 3.
Medication-Assisted Treatment Options
Medication-assisted treatment options for opiate withdrawal in pregnancy include:
- Methadone: the current drug of choice for treatment, but associated with longer treatment duration and more medication needed to treat neonatal abstinence syndrome (NAS) symptoms 4, 6
- Buprenorphine: emerging evidence supports its use during pregnancy, with benefits including shorter treatment duration, less medication needed to treat NAS symptoms, and shorter hospitalizations for neonates 4, 6
- Naltrexone: not a first-line treatment due to the requirement for detoxification and an opioid-free period, with more research needed to determine its safety and benefits in pregnant women 6
Importance of Multidisciplinary Approach
A multidisciplinary approach to management is crucial in the intrapartum and postpartum period, with all women being screened for opioid use disorder during pregnancy 5. This approach should involve collaboration between obstetricians, addiction treatment providers, and other healthcare professionals to provide sensitive and compassionate evidence-based care 7.
Key Considerations
Key considerations in managing opiate withdrawal in pregnancy include: