How to manage a pregnant woman in her second trimester with a history of daily heroin (opioid) use and occasional benzodiazepine use, who is ambivalent about treatment but concerned about her baby's well-being?

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

Immediately initiate medication-assisted treatment (MAT) with either methadone or buprenorphine—do not attempt detoxification or weaning during pregnancy, as acute withdrawal poses life-threatening risks to both mother and fetus. 1

Immediate Counseling and Treatment Initiation

Primary Message About Opioid Treatment

• Counsel the patient that continuing heroin use poses far greater risks than MAT: illicit opioid use leads to adverse pregnancy outcomes including fetal mortality, infection from IV drug use, poor prenatal care adherence, and unpredictable drug exposure 1
• Emphasize that MAT is the standard of care and is safe during pregnancy: both methadone and buprenorphine suppress cravings and withdrawal, prevent illicit opioid use, increase prenatal care adherence, and reduce infections 1
• Explicitly advise against detoxification: acute maternal withdrawal and relapse can be harmful or fatal to both mother and fetus/neonate 1

Choosing Between Methadone and Buprenorphine

Initiate buprenorphine if available through an office-based provider, as it offers greater accessibility and flexibility; reserve methadone for patients with severe OUD, history of IV drug use, or those who have previously succeeded on methadone. 1, 2

• Buprenorphine advantages: Can be prescribed in office-based settings, generally covered by insurance, allows for outpatient management, and may result in less severe neonatal opioid withdrawal syndrome 1, 2
• Methadone indications: History of successful methadone use, severe OUD requiring structured directly-observed therapy, inadequate response to buprenorphine, or IV drug use history 1
• Facilitate immediate referral: Either start buprenorphine yourself if waivered, or provide a "warm referral" (directly contact the treatment provider with patient permission rather than just giving a phone number) 3

Critical Benzodiazepine Counseling

Immediate Risk Communication

Strongly counsel the patient that concurrent benzodiazepine and opioid use dramatically increases risk of respiratory depression, profound sedation, coma, and death—this combination must be avoided. 4

• Explain the specific mechanism: The FDA black box warning states that concomitant use of opioids with benzodiazepines or other CNS depressants can result in profound sedation, respiratory depression, coma, and death 4
• Address the fetal/neonatal risks: While benzodiazepines in the third trimester are not associated with major congenital malformations (organogenesis is complete), late pregnancy exposure causes floppy infant syndrome, neonatal withdrawal, sedation, hypotonia, reluctance to suck, apneic spells, and cyanosis 5, 6
• Provide harm reduction if she cannot stop immediately: If complete cessation is not immediately achievable, educate about avoiding use together, never using alone, and having naloxone available 1

Benzodiazepine Management Strategy

• Do not prescribe benzodiazepines: Reserve concomitant prescribing only for patients where alternative treatment options are inadequate 4
• If she has a prescription: Coordinate with the prescribing physician to taper or discontinue, or switch to non-benzodiazepine alternatives for anxiety management 4
• Screen for benzodiazepine use disorder: If she meets criteria, she may need specialized addiction treatment for polysubstance use 1

Comprehensive Prenatal Care Structure

Multidisciplinary Team Assembly

Establish an interdisciplinary care team immediately, including addiction medicine specialists, behavioral health providers, social services, anesthesia consultation, and neonatology. 1, 7

• Addiction medicine/MAT provider: For ongoing medication management and dose adjustments throughout pregnancy 1
• Behavioral health referral: Address co-occurring psychiatric disorders, history of trauma (common in women with OUD), and provide cognitive behavioral therapy 1, 7
• Prenatal anesthesia consultation: Discuss pain management expectations for labor and delivery, as opioid-dependent women may experience opioid-induced hyperalgesia and require specialized pain control 1
• Social services: Address housing insecurity, food insecurity, and connect with peer support 1, 7
• Neonatology coordination: Ensure delivery occurs at a facility prepared to monitor, evaluate, and treat neonatal opioid withdrawal syndrome (NOWS) 4, 8

Screening and Testing Protocol

Test for HIV, hepatitis C, hepatitis B, tuberculosis, and sexually transmitted infections, as these are more common in women with OUD due to sharing paraphernalia, sex work, and incarceration. 1

• Screen for polysubstance use: Assess for stimulants, alcohol, tobacco, and other substances 1
• Evaluate for co-occurring psychiatric disorders: Depression, anxiety, PTSD are common 1, 7
• Screen for intimate partner violence and trauma history: Childbirth can trigger retraumatization in women with trauma history 1

Addressing Her Fears and Ambivalence

Explore her specific concerns about the baby, child welfare involvement, custody, and guilt about neonatal withdrawal—provide education and anticipatory guidance to build trust. 1

• Acknowledge her concern for the baby as a strength: Use motivational interviewing techniques to enhance her motivation for treatment 3
• Discuss child welfare laws in your state: Be transparent about mandatory reporting requirements so she understands the consequences and benefits of engaging in treatment 1
• Counsel about NOWS: Explain that 48-94% of opioid-exposed infants will experience neonatal withdrawal, but this is treatable and not a reason to avoid MAT, as untreated OUD poses greater risks 8
• Emphasize that MAT improves outcomes: Women on MAT have better prenatal care adherence, reduced pregnancy complications, higher birth weights, and decreased fetal mortality compared to continued illicit use 1

Ongoing Prenatal Monitoring

Fetal Surveillance

Obtain at least one third-trimester growth ultrasound due to association of OUD with low birth weight and small-for-gestational-age infants; consider serial growth scans if ongoing illicit substance use continues. 1

• Antenatal testing: While data are limited, consider non-stress testing or biophysical profiles in the setting of ongoing illicit opioid use 1
• Do not recommend delivery before 39 weeks: Unless there are other obstetric indications 1

MAT Dose Adjustments

Monitor for withdrawal symptoms and cravings throughout pregnancy, as physiologic changes (expanded volume of distribution, increased metabolism) often require dose increases, particularly in the second and third trimesters. 1

• For methadone: May need to split doses (2-3 times daily) or increase total daily dose to prevent breakthrough withdrawal 1
• For buprenorphine: Similarly may require dose adjustments; splitting doses can improve symptom control 1

Postpartum Planning

Contraception and Breastfeeding

Offer long-acting reversible contraception immediately after delivery if desired, and strongly encourage breastfeeding unless she is actively using illicit substances. 1

• Breastfeeding is encouraged on MAT: Both methadone and buprenorphine are compatible with breastfeeding and may reduce severity of NOWS 1
• Contraindication: Active or recent illicit drug use, including methamphetamine or ongoing benzodiazepine misuse 9, 5

Postpartum Follow-up

Arrange very close postpartum follow-up, as women are at particularly high risk of overdose and death in the first year after delivery due to stressors including care of infant with NOWS, threats of custody loss, and changes in access to care. 1

• Continue MAT throughout postpartum period: Do not discontinue after delivery 1
• Transition to primary care: Identify a primary care provider to manage ongoing substance use treatment after obstetric care concludes 1

Common Pitfalls to Avoid

• Never attempt detoxification during pregnancy: This increases risk of relapse, which can be fatal to mother and fetus 1
• Do not undertreat pain during labor: Opioid-dependent women may have tolerance and opioid-induced hyperalgesia; continue baseline MAT and provide neuraxial analgesia early 1
• Avoid opioid agonist-antagonists: Nalbuphine and butorphanol can precipitate withdrawal 1
• Do not separate mother and infant based on substance use disorder alone: This worsens outcomes 1
• Never prescribe benzodiazepines concurrently with opioids: This combination is potentially fatal 4