How would you manage a pregnant patient in their second trimester with opioid use disorder, using heroin daily and benzodiazepines (Benzodiazepines) occasionally?

Management of Pregnant Patient in Second Trimester with Daily Heroin Use and Occasional Benzodiazepine Use

Immediately initiate medication-assisted treatment (MAT) with buprenorphine or methadone—do not attempt detoxification, as acute opioid withdrawal during pregnancy poses serious risks to both mother and fetus, including potential fetal death. 1, 2

Immediate Medication-Assisted Treatment Initiation

Choice of MAT Agent

Buprenorphine is the preferred first-line agent over methadone when both are available, as neonates exposed to buprenorphine require less medication to treat neonatal opioid withdrawal syndrome (NOWS), have shorter treatment duration (52.0% vs 69.2% incidence of NAS), and shorter hospital stays. 3, 2, 4

• For buprenorphine initiation: Begin when the patient is in mild-moderate withdrawal, typically 12-24 hours after last heroin use. 2
• Methadone should be considered if the patient has: (1) history of successful methadone use with sustained abstinence, (2) history of intravenous drug use or severe OUD requiring structured directly observed therapy, or (3) inadequate response to buprenorphine. 1
• Initial methadone dosing: Start at 20-30 mg and titrate gradually over weeks to 80-120 mg per day, though some pregnant women require significantly higher doses. 1

Critical Pitfall to Avoid

Never pursue detoxification or attempt to wean opioids before delivery—this dramatically increases relapse risk, which can lead to accidental overdose from decreased tolerance, obstetric complications, and abrupt cessation of prenatal care. 1, 2

Management of Concurrent Benzodiazepine Use

The concurrent use of benzodiazepines with buprenorphine or methadone significantly increases risk of profound sedation, respiratory depression, coma, and death. 5

• Address benzodiazepine use through behavioral interventions rather than abrupt cessation, as withdrawal can also be dangerous. 2
• If benzodiazepines must be continued, this requires extremely close monitoring and represents a situation where alternative treatment options are inadequate—reserve this combination only when absolutely necessary. 5
• Coordinate with addiction psychiatry for management of benzodiazepine dependence alongside OUD treatment. 2

Comprehensive Care Team Assembly

Establish an interdisciplinary team immediately that coordinates at minimum: 2

• MAT provider (addiction medicine specialist or waivered prescriber)
• Obstetric care provider
• Behavioral health counselor/social worker
• Anesthesia consultation for labor planning

Behavioral Health Integration

Implement evidence-based psychosocial interventions concurrently with MAT: 2

• Use motivational interviewing techniques rather than confrontational approaches
• Provide cognitive behavioral therapy, contingency management, or coping skills training—ongoing psychological support is linked to improved outcomes for both mother and neonate, with lower rates of NOWS. 2
• Continue behavioral interventions for at least 6 months postpartum, as substance dependence is a chronic relapsing illness requiring longitudinal care. 2

Prenatal Care Protocol

Initiate comprehensive prenatal care immediately with the following components: 2

• Antenatal testing throughout pregnancy to monitor for relapse and adverse outcomes
• Screen for infectious diseases associated with intravenous drug use (HIV, hepatitis B and C)
• Assess for trauma history—chronic opioid use and OUD are associated with childhood trauma and interpersonal violence, which can lead to retraumatization during childbirth. 1
• Prenatal anesthesia consultation to plan for labor pain management 1

Medication Dosing Adjustments During Pregnancy

Be prepared to adjust MAT dosing in second and third trimesters: 1

• Methadone levels may decrease due to expanded volume of distribution and progesterone-increased cytochrome P450 metabolism
• Adjust dosing only if current dose is insufficient to prevent withdrawal symptoms or reduce cravings
• Consider split dosing (dividing daily dose into 2-3 administrations) rather than increasing total dose initially 1

Labor and Delivery Planning

Continue daily MAT medication throughout labor to prevent acute withdrawal—do not discontinue or reduce the dose. 1, 3, 2

Pain Management During Labor

• Encourage neuraxial labor analgesia (epidural or combined spinal-epidural) in early labor or as soon as contractions become uncomfortable—this is highly effective in opioid-dependent women. 1, 3, 2
• With effective neuraxial analgesia, supplementation with systemic opioids should not be required. 1
• Evidence supports dividing the maintenance medication dose (buprenorphine or methadone) into 2-3 doses during labor to improve pain control. 1

Medications to Avoid During Labor

Avoid opioid agonist/antagonists (nalbuphine, butorphanol) as they can precipitate opioid withdrawal. 1, 3, 2

Avoid inhaled nitrous oxide due to reduced efficacy in opioid-dependent women and increased sedation risk. 1, 3, 2

Postpartum Pain Management

Use a multimodal approach starting with non-opioid pain relief: 3, 2

• First-line: Acetaminophen and NSAIDs (unless contraindicated)
• Continue maintenance therapy (buprenorphine or methadone) at the same dose
• If additional analgesia needed: Full opioid agonists with strong mu-receptor affinity (fentanyl or hydromorphone) can be added—buprenorphine's partial agonist properties do not preclude use of full agonists for acute pain. 1, 3

Neonatal Considerations

Prepare for neonatal opioid withdrawal syndrome (NOWS): 5

• NOWS is expected and manageable—ensure neonatology experts will be available at delivery. 5, 6
• Onset typically occurs in first days after birth with symptoms including irritability, excessive crying, tremors, hyperactive reflexes, increased respiratory rate, increased stools, sneezing, yawning, vomiting, and fever. 7
• Duration varies from days to weeks or months—intensity does not always correlate with maternal dose. 7
• Breastfeeding is beneficial for infants when mother is maintained on stable dose of opioid agonist medication. 6

Social Services Coordination

Connect patient to comprehensive support services: 2

• Mutual help groups (Narcotics Anonymous, SMART Recovery)
• Address transportation and childcare needs
• Coordinate early with local department of children's services—proactive engagement is preferable to crisis intervention
• Screen for housing instability, food insecurity, and intimate partner violence

Key Safety Monitoring

Monitor for QTc prolongation with methadone: 1

• Caution if QTc is 450-499 msec
• Strongly consider alternative therapy if QTc ≥500 msec 1

Urine toxicology screening should be performed to check for concurrent substance use, particularly given the occasional benzodiazepine use reported. 1