What are the guidelines for managing a 7-week pregnant female with a history of fentanyl and cocaine misuse, presenting with last use 1 day ago, in an outpatient setting?

Management of Pregnant Woman with Fentanyl and Cocaine Use in Outpatient Detox Setting

Medication-Assisted Treatment (MAT) with methadone or buprenorphine should be initiated immediately rather than pursuing detoxification, as acute opioid withdrawal during pregnancy poses serious risks of relapse, overdose, obstetric complications, and cessation of prenatal care that can be harmful or fatal to both mother and fetus. 1

Immediate Management Priorities

Initiate MAT, Not Detoxification

• Methadone or buprenorphine are the only opioids considered safe throughout all trimesters of pregnancy and should be offered as first-line maintenance therapy for opioid use disorder. 2
• Detoxification during pregnancy is not the preferred treatment option due to increased relapse risk, which can lead to accidental overdose from decreased tolerance, obstetric complications, and abrupt cessation of prenatal care. 1
• If this patient insists on detoxification despite counseling, it should only be undertaken with careful patient selection, close MAT provider supervision, mandatory behavioral health management continuing at least 6 months postpartum, and antenatal testing until delivery to minimize relapse. 1

Establish Comprehensive Care Team

The outpatient facility must coordinate at minimum: 1

• MAT provider (for buprenorphine or methadone initiation)
• Obstetric care provider (for prenatal care starting immediately at 7 weeks gestation)
• Behavioral health counselor/social worker (mandatory throughout treatment and postpartum)

Address Polysubstance Use

• Screen for all concurrent substance use, as polysubstance use is common and affects withdrawal management. 3
• Cocaine use during pregnancy increases risks of preterm labor, placental abruption, intrauterine growth retardation, low birth weight, congenital anomalies, and pre-eclampsia-like syndrome. 4, 5
• The combination of fentanyl and cocaine creates complex withdrawal patterns and increased maternal-fetal risks. 6

Specific Treatment Protocol

MAT Initiation (Day 1-3)

Buprenorphine is preferred over methadone when both are available, as neonates exposed to buprenorphine typically require less medication to treat neonatal opioid withdrawal syndrome (NOWS), have shorter treatment duration, and shorter hospital stays. 2

• Begin buprenorphine induction when patient is in mild-moderate withdrawal (typically 12-24 hours after last fentanyl use, though fentanyl may require longer).
• Neither methadone nor buprenorphine are associated with birth defects. 2
• Patient should remain on prescribed MAT medication throughout entire pregnancy—do not attempt to wean or taper. 1, 2

Behavioral Health Management (Mandatory)

• Implement motivational interviewing techniques rather than confrontational approaches. 3
• Provide cognitive behavioral therapy, contingency management, or coping skills training as evidence-based psychosocial interventions. 3
• Ongoing psychological support during treatment is linked to improved outcomes for both pregnant woman and neonate, with lower rates of NOWS. 1
• Continue behavioral health management for at least 6 months after delivery, as relapse risk remains elevated during early recovery. 1, 3

Prenatal Care Integration

• Initiate prenatal care immediately at 7 weeks gestation with obstetric provider. 1
• MAT increases adherence to prenatal care and reduces infections associated with intravenous drug use. 1
• Coordinate antenatal testing throughout pregnancy to monitor for relapse and adverse outcomes. 1
• Arrange for delivery at a facility prepared to monitor, evaluate, and treat neonatal opioid withdrawal syndrome. 1

Addressing Cocaine Use

• No FDA-approved medications exist specifically for cocaine use disorder. 3
• Transition to behavioral interventions as primary treatment modality for cocaine use. 3
• Implement harm reduction strategies including education about dose-related risks, avoiding polysubstance use, and recognizing signs of toxicity requiring emergency care. 3
• Monitor for cocaine-related complications: dilated pupils, increased heart rate/blood pressure/respirations, agitated sensorium, preterm labor, and pre-eclampsia symptoms. 5

Labor and Delivery Planning

Pain Management Protocol

• Women should remain on their daily dose of MAT medication throughout labor to prevent acute withdrawal. 1
• Dividing the maintenance medication dose (buprenorphine or methadone) into 2-3 doses can improve pain control during labor. 1
• Encourage neuraxial labor analgesia (epidural or combined spinal-epidural) in early labor, as this is highly effective in opioid-dependent women. 1, 2
• Avoid opioid agonist/antagonists (nalbuphine, butorphanol) as they can precipitate opioid withdrawal. 1, 2
• Avoid inhaled nitrous oxide due to reduced efficacy and increased sedation risk in opioid-dependent women. 1, 2

Postpartum Pain Management

• Use multimodal approach starting with non-opioid pain relief (acetaminophen, NSAIDs). 1, 2
• Continue maintenance therapy (buprenorphine or methadone) postpartum. 2
• If additional analgesia needed, use full opioid agonists with strong mu receptor affinity (fentanyl or hydromorphone) rather than partial agonists. 1, 2

Critical Pitfalls to Avoid

• Never abruptly discontinue methadone or buprenorphine during pregnancy, as withdrawal poses serious risks to both mother and fetus. 2
• Do not withhold MAT in favor of detoxification without extensive counseling about risks and mandatory intensive support systems. 1
• Do not use codeine during breastfeeding due to reports of neonatal toxicity and death in ultra-rapid metabolizers. 1, 2
• Do not delay prenatal care—early engagement improves birth outcomes. 5

Social Services and Support

• Connect patient to mutual help groups (Narcotics Anonymous, SMART Recovery) for ongoing support with initial weekly monitoring. 1, 3
• Address transportation and childcare needs to ensure appointment adherence. 1
• Coordinate with local department of children's services early in treatment, discussing involvement transparently with patient. 1
• Provide extensive outpatient follow-up after delivery including breastfeeding counseling, continuous substance use disorder counseling, and contraception counseling. 1

Longitudinal Care Approach

• Treat substance dependence as a chronic relapsing illness requiring longitudinal care rather than acute intervention alone. 3
• Continue behavioral interventions for at least 6 months postpartum. 1, 3
• Screen for comorbid mental health disorders (anxiety, depression, PTSD, bipolar disorder) which are more common in patients with substance use disorders. 1