What is the best next step in managing a 27-year-old primigravid(a woman in her first pregnancy) woman at 8 weeks gestation with a history of intravenous (IV) heroin use, presenting with a desire to quit due to pregnancy?

From the Guidelines

The best next step in management for this 27-year-old pregnant woman with daily heroin use is to initiate medication-assisted treatment (MAT) with buprenorphine, as it has been shown to be effective in suppressing illicit opioid use in pregnant women with opioid use disorder (OUD) at a daily dosage of 16 mg 1.

Key Considerations

• The patient's history of intravenous heroin use and her desire to quit necessitate immediate attention to prevent withdrawal and its associated risks to both mother and fetus.
• Buprenorphine is preferred due to its better safety profile, less severe neonatal abstinence syndrome, and outpatient administration options, making it a more suitable choice for pregnant women 1.
• The initiation of buprenorphine requires the patient to be experiencing opioid withdrawal, and it is recommended that women abstain from short-acting opioids at least 12-24 hours before induction and long-acting opioids 36-48 hours before induction 1.

Management Plan

• The patient should be assessed for opioid withdrawal using a validated opioid withdrawal scale before initiating buprenorphine treatment.
• A daily dosage of 16 mg of buprenorphine is recommended to suppress illicit opioid use in most pregnant women with OUD, but the dosage may need to be adjusted based on individual patient needs 1.
• The patient should also be referred to comprehensive prenatal care, substance use counseling, and social services to address her housing and financial stability.
• Regular monitoring for relapse, infectious disease screening (HIV, hepatitis), and psychosocial support are essential components of her care plan.

Prioritizing Harm Reduction

• The approach prioritizes harm reduction and supports both maternal and fetal health outcomes while addressing the underlying substance use disorder.
• It is crucial to consider the patient's overall well-being, including her physical and mental health, as well as her social and economic situation, when developing a treatment plan.

From the FDA Drug Label

The data on use of buprenorphine, the active ingredient in Buprenorphine Sublingual Tablets, in pregnancy, are limited; however, these data do not indicate an increased risk of major malformations specifically due to buprenorphine exposure Untreated opioid addiction in pregnancy is associated with adverse obstetrical outcomes such as low birth weight, preterm birth, and fetal death Dosage adjustments of buprenorphine may be required during pregnancy, even if the patient was maintained on a stable dose prior to pregnancy. Withdrawal signs and symptoms should be monitored closely and the dose adjusted as necessary

The best next step in management of this patient is to consider buprenorphine treatment for opioid addiction, as untreated opioid addiction can lead to adverse obstetrical outcomes.

• The patient should be closely monitored for withdrawal signs and symptoms and the dose adjusted as necessary.
• It is essential to advise the patient of the potential risk to the fetus and the importance of prenatal care. 2

From the Research

Management of Opioid Withdrawal in Pregnancy

The patient's situation requires careful consideration of the best approach to manage opioid withdrawal while ensuring the health and safety of both the mother and the fetus.

• The patient is 8 weeks pregnant and has a history of intravenous heroin use, with the last injection 6 hours prior to the visit.
• She expresses a desire to quit heroin due to its potential harm to the baby.

Treatment Options

Considering the patient's pregnancy and opioid use disorder, the following treatment options can be explored:

• Buprenorphine: Studies have shown that buprenorphine is effective in managing opioid withdrawal, with a lower average withdrawal score and higher treatment completion rates compared to other medications like clonidine or lofexidine 3.
• Methadone: Methadone is also a widely used medication for opioid use disorder, but it may be associated with longer treatment duration and more medication needed to treat neonatal abstinence syndrome (NAS) symptoms compared to buprenorphine 4.
• Naltrexone: Naltrexone is not typically used as a first-line treatment for opioid use disorder in pregnancy, as it requires detoxification and an opioid-free period, which may not be suitable for all patients 4.

Best Next Step

Given the patient's situation, the best next step in management would be to initiate buprenorphine treatment, as it has been shown to be effective in managing opioid withdrawal and has a more favorable profile compared to other medications, especially in pregnant women 3, 4. It is essential to closely monitor the patient's progress and adjust the treatment plan as needed to ensure the best possible outcomes for both the mother and the fetus. Additionally, the patient should be educated on the potential risks and benefits of opioid withdrawal treatment during pregnancy and involved in the decision-making process 5, 6, 7.