What narcotic (opioid) pain medications can be prescribed during pregnancy?

Opioid Pain Medications During Pregnancy

For pregnant women requiring pain management, 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 Approach for Pain in Pregnancy

• Non-opioid medications should be the first-line treatment for pain during pregnancy:
  • Acetaminophen is recommended as first-line medication due to its favorable safety profile 2
  • NSAIDs can be used only during the second trimester if necessary 2

Opioid Options When Absolutely Necessary

• For severe pain not managed by non-opioids, the following considerations apply:
  • Methadone and buprenorphine are the safest opioid options during pregnancy but are primarily indicated for opioid use disorder rather than pain management 1
  • If opioids are needed for severe pain, they should be prescribed at the lowest effective dose for the shortest duration possible 2
  • Full opioid agonists like fentanyl or hydromorphone may be used for acute severe pain when necessary 3

Risks of Opioid Use in Pregnancy

• Prolonged opioid use during pregnancy can result in neonatal opioid withdrawal syndrome 4
• Opioids cross the placenta and may produce respiratory depression in neonates 4
• Opioid use during pregnancy has been associated with:
  • Stillbirth and poor fetal growth 1
  • Preterm delivery 1
  • Potential birth defects 1

Special Considerations for Different Opioids

• Codeine should be avoided during pregnancy and breastfeeding due to reports of neonatal toxicity and death 1
• Tramadol carries similar concerns to codeine and should be avoided 5
• Morphine use during pregnancy has not shown a clear association with major birth defects but can cause neonatal opioid withdrawal syndrome 4
• Strong opioid agonists and long half-life opioids are associated with higher risk of neonatal opioid withdrawal syndrome 6

Management of Opioid-Dependent Pregnant Women

• Women already on opioid maintenance therapy should:
  • Continue their prescribed medications throughout pregnancy 3
  • Not attempt acute detoxification or weaning during pregnancy due to risks of maternal withdrawal and relapse 3
  • Receive neuraxial labor analgesia (epidural) during delivery 3

Postpartum Pain Management

• For women with opioid dependence, postpartum pain should be managed with:
  • A multimodal approach starting with non-opioid pain relief 3
  • Continuation of maintenance therapy (buprenorphine or methadone) 3
  • Addition of full opioid agonists (e.g., fentanyl or hydromorphone) if needed for acute pain 3

Important Pitfalls to Avoid

• Avoid opioid agonist/antagonists like nalbuphine or butorphanol as they can precipitate opioid withdrawal 3
• Avoid inhaled nitrous oxide in opioid-dependent women due to reduced efficacy and increased sedation risk 3
• Never abruptly discontinue methadone or buprenorphine during pregnancy as withdrawal poses risks to both mother and fetus 1
• Recognize that delivery for women who have used opioids during pregnancy should take place in a facility prepared to monitor and treat neonatal opioid withdrawal syndrome 5