What is the recommended approach for managing addiction in pregnancy, including medication-assisted treatment (MAT) with methadone (Dolophine) or buprenorphine (Subutex) and behavioral therapies?

Management of Addiction in Pregnancy

Pregnant women with opioid use disorder should be offered medication-assisted treatment (MAT) with either methadone or buprenorphine and maintained on these medications throughout pregnancy, labor, and postpartum—acute detoxification or withdrawal attempts are not recommended due to risks of maternal relapse and fetal harm. 1, 2

Standard of Care: Medication-Assisted Treatment

First-Line Pharmacotherapy Options

Both methadone and buprenorphine are acceptable first-line treatments for opioid use disorder (OUD) in pregnancy, with neither medication demonstrating superiority over the other in overall efficacy. 1, 2 However, important differences exist:

Methadone characteristics:

• Full mu-opioid receptor agonist with established safety record and no association with birth defects 2
• Requires daily directly observed dosing at federally accredited opioid treatment programs 1
• Associated with better treatment retention compared to buprenorphine 1
• Ideal for patients with history of successful methadone use, severe OUD, intravenous drug use, or inadequate response to buprenorphine 1

Buprenorphine characteristics:

• Partial mu-opioid receptor agonist with no association with birth defects 2, 3
• Can be prescribed for home dosing with less frequent clinic visits 1
• Associated with reduced severity and frequency of neonatal opioid withdrawal syndrome (NOWS), less medication needed for NOWS treatment, and shorter neonatal hospital stays 1, 2
• Recent large cohort study showed 52.0% incidence of neonatal abstinence syndrome with buprenorphine versus 69.2% with methadone 4
• Associated with lower rates of preterm birth (14.4% vs 24.9%), small for gestational age (12.1% vs 15.3%), and low birth weight (8.3% vs 14.9%) compared to methadone 4

Critical Management Principles

Continue MAT throughout pregnancy:

• Women should remain on prescribed medications throughout all trimesters 1, 2
• MAT suppresses cravings and withdrawal, prevents illicit opioid use, increases prenatal care adherence, and reduces infections from intravenous drug use 1
• Acute detoxification or weaning before delivery is contraindicated for most women due to risk of acute maternal withdrawal and relapse, which can be harmful or fatal to mother and fetus 1, 2

Medication selection approach:

• Use shared decision-making when choosing between methadone and buprenorphine 1
• Consider benefits and burdens of daily observed dosing (methadone) versus home dosing (buprenorphine) 1
• Factor in patient's past treatment experience, severity of OUD, and access to treatment facilities 1

Labor and Delivery Management

Continuation of MAT During Labor

Maintain baseline MAT dosing:

• Women must continue their daily dose of methadone or buprenorphine throughout labor to treat the underlying disorder and prevent acute withdrawal 1, 2
• Consider dividing the maintenance dose into 2-3 doses during labor to improve pain control 1

Pain Management Strategies

Neuraxial analgesia is first-line:

• Epidural or combined spinal-epidural should be encouraged in early labor or as soon as contractions become uncomfortable 1, 2
• This modality is highly effective in opioid-dependent women and eliminates need for supplemental systemic opioids when effective 1

Medications to avoid:

• Inhaled nitrous oxide should be avoided due to reduced efficacy and increased sedation risk in opioid-dependent women 1, 2
• Opioid agonist/antagonists (nalbuphine, butorphanol) are contraindicated as they can precipitate acute opioid withdrawal 1, 2

Postpartum Pain Management

Multimodal approach starting with non-opioids:

• First-line: NSAIDs and acetaminophen unless contraindicated 1
• Continue baseline MAT (methadone or buprenorphine) throughout postpartum period 2
• For persistent severe pain after vaginal delivery (which is unusual and should prompt evaluation for complications): short course of low-dose opioids may be considered 1

For women on buprenorphine requiring additional opioid analgesia:

• Full opioid agonists with strong mu-receptor affinity (fentanyl or hydromorphone) can provide adequate pain relief despite buprenorphine's partial agonist properties 1, 2
• Additional systemic opioids should not be ordered routinely but may be necessary 1

Discharge planning:

• Communicate with outpatient opioid treatment program regarding in-hospital dosing and additional pain medications given 1
• Treatment of acute pain rarely requires more than 3 days of pain medication 1
• Women should be counseled that untreated pain can trigger relapse, and safeguards like having family members dispense medication can be used 1

Behavioral and Psychosocial Support

Comprehensive interdisciplinary care:

• Prenatal outpatient anesthesia consultation is beneficial 1
• Cognitive behavioral therapy or other counseling before delivery is recommended 1
• Interdisciplinary approach involving obstetric team and addiction medicine team ensures coordinated care 1

Addressing patient concerns:

• Many opioid-dependent women have fears about labor pain, having an infant with neonatal withdrawal, and their own relapse risk 1
• Prenatal care provides opportunity to explore these fears, provide education and anticipatory guidance 1

Special Considerations and Pitfalls

Neonatal opioid withdrawal syndrome (NOWS):

• Expected and treatable outcome of prolonged opioid use in pregnancy 2, 3
• Presents as irritability, hyperactivity, abnormal sleep pattern, high-pitched cry, tremor, vomiting, diarrhea, and failure to gain weight 3
• Signs usually occur in first days after birth 3
• Newborns should be observed and managed accordingly 2, 3

Pregnancy as window of opportunity:

• Women have access to health insurance and are often motivated toward positive health behaviors during pregnancy 1
• High-quality treatment interventions during this time can improve maternal and child health with far-reaching benefits for future generations 1

Untreated OUD risks:

• Associated with low birth weight, preterm birth, fetal death, and continued illicit opioid use 2, 3
• Benefits of MAT throughout pregnancy outweigh risks 3