What is the recommended treatment approach for opioid use disorder in pregnant individuals using buprenorphine?

Buprenorphine for Opioid Use Disorder in Pregnancy

Medication-assisted treatment (MAT) with buprenorphine is a recommended first-line treatment for opioid use disorder (OUD) in pregnancy, with evidence showing more favorable neonatal outcomes compared to methadone while maintaining similar maternal safety profiles. 1, 2

Benefits of Buprenorphine in Pregnancy

Buprenorphine offers several advantages over other treatment options:

• Neonatal outcomes: Buprenorphine exposure is associated with:

  • 27% lower risk of neonatal abstinence syndrome compared to methadone (52.0% vs 69.2%) 2
  • 42% lower risk of preterm birth (14.4% vs 24.9%) 2
  • 28% lower risk of small-for-gestational-age infants (12.1% vs 15.3%) 2
  • 44% lower risk of low birth weight (8.3% vs 14.9%) 2
  • Shorter duration of treatment and hospital stays for neonates 3

• Maternal benefits:

  • Office-based treatment availability (unlike methadone which requires specialized clinics) 3
  • Similar safety profile to methadone for maternal complications (3.3% vs 3.5%) 2
  • No increased risk of cesarean delivery compared to methadone 2

Treatment Protocol

Initiation and Maintenance

1. Continue treatment throughout pregnancy - Discontinuing buprenorphine during pregnancy is not recommended due to high risk of relapse and associated maternal and fetal harms 1

2. Dosing considerations:

   • Pregnant women may require dosage adjustments during pregnancy due to physiologic changes
   • Split doses may be necessary to prevent withdrawal symptoms, particularly in second and third trimesters 3
   • High-dose initiation protocols may be considered for some patients 4

3. Monitoring:

   • Regular prenatal care with close monitoring
   • Monthly counseling sessions are recommended (though access may be challenging) 3

Labor and Delivery Management

1. Maintain medication during labor:

   • Women should remain on their daily dose of buprenorphine throughout labor to prevent withdrawal 3, 1
   • Consider dividing maintenance dose into 2-3 doses to improve pain control 3

2. Pain management:

   • Encourage early neuraxial analgesia (epidural) 3
   • Avoid opioid agonist/antagonists (nalbuphine, butorphanol) as they can precipitate withdrawal 3
   • For acute pain, full opioid agonists with strong mu-receptor affinity (fentanyl, hydromorphone) can be used if needed 3
   • Avoid nitrous oxide due to reduced efficacy and increased sedation risk 3

Postpartum Considerations

1. Continue treatment postpartum - Plans should be made during pregnancy to support continuation of treatment after delivery 3

2. Breastfeeding - Generally considered beneficial for women maintained on stable buprenorphine doses 5

3. Monitor infant for neonatal abstinence syndrome - While less severe than with methadone, NAS still occurs in approximately 52% of infants exposed to buprenorphine 2

Patient Selection Considerations

Buprenorphine may be particularly appropriate for patients with:

• Previous good response to buprenorphine 3
• Access to a buprenorphine prescriber 3
• Inadequate response to methadone 3

Methadone may be more appropriate for patients with:

• History of successful methadone use 3
• History of intravenous drug use or severe OUD requiring structured treatment setting 3
• Concurrent benzodiazepine or CNS depressant use 3
• Inadequate response to buprenorphine 3

Important Cautions

• Risk of withdrawal: Acute detoxification or attempting to wean opioids before delivery is not recommended due to risk of maternal withdrawal and relapse 3, 1

• Neonatal monitoring: Infants should be observed for signs of neonatal opioid withdrawal syndrome, which typically appears in the first days after birth 6

• Respiratory depression: Monitor neonates for respiratory depression; have naloxone available for reversal if needed 6

• Maternal consent: Ensure appropriate consent is obtained to coordinate care between obstetric and addiction medicine teams 3

Human studies have not shown increased risk of major malformations with buprenorphine use in pregnancy 6, making it a safe and effective option for managing OUD during pregnancy while optimizing maternal and neonatal outcomes.