What are the guidelines for opioid use in pregnancy?

Opioid Use in Pregnancy

For Pregnant Women with Opioid Use Disorder (OUD)

Methadone or buprenorphine are the only opioids considered safe throughout all trimesters of pregnancy and should be offered as maintenance therapy to all pregnant women with OUD—these medications should never be used for pain management in pregnancy, only for treating opioid use disorder. 1

Key Treatment Principles

• Continue maintenance therapy throughout pregnancy and postpartum without attempting detoxification or abrupt discontinuation, as withdrawal poses significant risks to both mother and fetus including relapse, treatment dropout, and fetal distress. 2, 1

• Buprenorphine demonstrates superior neonatal outcomes compared to methadone, with neonates typically requiring less medication to treat neonatal opioid withdrawal syndrome (NOWS), shorter treatment duration, and shorter hospital stays. 1

• Both medications have established safety profiles with no association with birth defects, though methadone has a longer track record of safety data in pregnancy. 1

• Medication dose adjustments may be needed as pregnancy advances due to increased metabolism and blood volume, and higher doses are not associated with more severe NOWS. 3

Critical Pitfalls to Avoid

• Never switch medications during pregnancy unless absolutely necessary, as this can destabilize opioid abstinence and increase relapse risk. 3

• Avoid opioid agonist-antagonists (nalbuphine, butorphanol) as they can precipitate acute withdrawal. 1

• Do not use inhaled nitrous oxide in opioid-dependent women due to reduced efficacy and increased sedation risk. 1

For Pain Management in Opioid-Naïve Pregnant Women

NSAIDs and acetaminophen should be first-line treatments for pain in pregnancy unless contraindicated, with opioids reserved only for severe pain unresponsive to non-opioid options. 2, 1

Postpartum Pain After Vaginal Delivery

• Start with NSAIDs and acetaminophen as standing medications for routine vaginal delivery. 2

• Short course of low-dose opioids (limited supply) may be considered only for severe pain not controlled by non-opioids. 2

• Severe pain after vaginal delivery is unusual and should prompt evaluation for unrecognized complications such as hematoma or infection. 2

Postpartum Pain After Cesarean Delivery

• Neuraxial morphine or hydromorphone should be administered at the time of cesarean delivery. 2

• Standing scheduled medications: Acetaminophen 975 mg every 8 hours plus ketorolac 30 mg IV every 6 hours for 24 hours, then transition to ibuprofen 600 mg every 6 hours. 2

• Limit opioid prescriptions at discharge through shared decision-making to no more than the equivalent of 20 tablets of 5-mg oxycodone (maximum 30 mg daily), and only if the woman required opioids during hospitalization. 2

• If no opioids were needed in the hospital, do not prescribe at discharge. 2

Labor Analgesia

Neuraxial analgesia (epidural) should be strongly encouraged for all pregnant women, particularly those with OUD or on maintenance therapy. 2, 1

For Pregnant Women with OUD Requiring Pain Management

Women on methadone or buprenorphine maintenance therapy require a specialized multimodal approach that continues their baseline medication while addressing acute pain separately. 2, 1

Intrapartum and Postpartum Pain Protocol

• Continue baseline maintenance therapy (methadone or buprenorphine) at the usual dose without interruption. 1

• Provide neuraxial analgesia (epidural) during labor as the primary pain management strategy. 2, 1

• For postpartum pain lasting >24 hours, start with non-opioid multimodal analgesia (NSAIDs, acetaminophen), then add full opioid agonists (fentanyl or hydromorphone) if pain persists despite non-opioid therapy. 2, 1

• Recognize that women with opioid dependence experience higher pain levels due to opioid tolerance and opioid-induced hyperalgesia, requiring more aggressive pain management than opioid-naïve women. 2

Maternal and Fetal Risks

Opioid use in pregnancy carries significant risks including stillbirth, poor fetal growth, preterm delivery, birth defects, and neonatal opioid withdrawal syndrome. 2

Neonatal Considerations

• All deliveries for women using opioids must occur at facilities equipped to monitor, evaluate, and treat NOWS, with neonatology expertise available. 2, 4, 5, 6

• NOWS is an expected and manageable condition that requires protocol-driven treatment, typically with methadone or morphine in the context of non-pharmacological supportive care. 3

• Breastfeeding is safe and beneficial for women maintained on stable doses of methadone or buprenorphine and should be encouraged. 3, 7

Specific Medication Warnings

• Codeine must be avoided during breastfeeding due to reports of neonatal toxicity and death; if absolutely necessary, limit to lowest dose and 4-day supply maximum. 2, 1

• Tramadol carries similar concerns to codeine and should be avoided during breastfeeding. 8

Preconception Counseling

Before initiating any opioid therapy for chronic pain in reproductive-age women, discuss family planning and how long-term opioid use will affect future pregnancy. 2

• Carefully weigh risks versus benefits with the patient before starting opioid therapy during pregnancy, using shared decision-making. 2

• Universal screening for substance use should occur at the first prenatal visit using validated tools such as the NIDA Quick Screen. 2