What opioid medication is safe to use during all trimesters of pregnancy?

Opioid Medications in Pregnancy: Safety Considerations Across Trimesters

Methadone and buprenorphine are the only opioids considered safe for use throughout all trimesters of pregnancy, and they should only be used for opioid use disorder treatment rather than pain management. 1

First-Line Recommendations for Pregnant Women with Opioid Use Disorder

• Methadone and buprenorphine are the recommended medications for pregnant women with opioid use disorder (OUD) and should be offered as maintenance therapy throughout pregnancy 1
• The choice between methadone and buprenorphine should be individualized based on:
  • Patient's prior response to either medication 1
  • Availability of prescribers 1
  • Concurrent use of benzodiazepines or other CNS depressants (may favor methadone) 1

Comparative Safety Profile

Methadone

• Established safety record in pregnancy with no association with birth defects 1
• Women on methadone are more likely to complete treatment compared to those on buprenorphine 1
• May be associated with more non-serious maternal cardiovascular events 1
• Neonates exposed to methadone may require more medication to treat neonatal opioid withdrawal syndrome (NOWS) and have longer hospital stays compared to buprenorphine 1

Buprenorphine

• No association with birth defects 1
• Neonates exposed to buprenorphine typically have:
  • Less medication needed to treat NOWS
  • Shorter duration of treatment
  • Shorter hospital stays
  • Better outcomes for birthweight, birth length, and gestational age 1
• Both buprenorphine monotherapy (Subutex) and combination therapy with naloxone (Suboxone) appear safe in pregnancy 1

Important Cautions and Considerations

• Opioids used in pregnancy may be associated with risks including stillbirth, poor fetal growth, preterm delivery, and birth defects 1
• Neonatal opioid withdrawal syndrome is a consistent and common adverse effect of methadone and buprenorphine use during pregnancy 1
• Codeine should be avoided during breastfeeding due to reports of neonatal toxicity and death 1
• For pregnant women with OUD, medication-assisted withdrawal (detoxification) is not recommended as standard care due to high relapse rates 1

Pain Management During Pregnancy and Labor

• For opioid-naïve pregnant women requiring pain management:
  • NSAIDs and acetaminophen should be first-line treatments (unless contraindicated) 1
  • Short-acting opioids should be limited to cases of severe pain not managed by non-opioid options 1
• For labor pain, neuraxial analgesia (epidural) should be encouraged 1
• If opioids are needed during labor, fentanyl may be used with appropriate monitoring:
  • Intravenous fentanyl appears safe with minimal side effects on both mother and infant 2, 3
  • No long-term fetal effects have been identified with IV fentanyl use during labor 3, 4
  • Fentanyl crosses the placental barrier, but studies show normal neonatal neurological and adaptive capacities at 2 and 24 hours after birth 3, 4

Postpartum Pain Management

• For women with OUD, postpartum pain should be managed with a multimodal approach starting with non-opioid pain relief 1
• If pain persists beyond 24 hours, full opioid agonists like fentanyl or hydromorphone may be considered 1
• Women on buprenorphine or methadone for OUD should continue their maintenance therapy during the postpartum period 1

Key Pitfalls to Avoid

• Never abruptly discontinue methadone or buprenorphine during pregnancy as withdrawal poses risks to both mother and fetus 1
• Do not initiate naltrexone therapy during pregnancy due to insufficient safety data 1
• Avoid codeine in breastfeeding mothers due to risk of neonatal toxicity 1
• Do not use conventional opioid dosing for pain in women maintained on methadone or buprenorphine, as they will likely require higher doses and specialized pain management approaches 1