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

Immediately initiate medication-assisted treatment (MAT) with buprenorphine or methadone for this patient's opioid use disorder, as continuing heroin use poses far greater risks to both mother and fetus than MAT, and acute withdrawal can be life-threatening to both. 1

Initial Counseling Approach

Emphasize that MAT is the standard of care and is safe during pregnancy, suppressing cravings and withdrawal while preventing illicit opioid use. 1 Counsel her that continuing heroin use carries far greater risks than treatment, including adverse pregnancy outcomes and fetal mortality. 1

• Address her ambivalence directly by explaining that heroin use poses significant risks including preterm birth, low birth weight, small-for-gestational-age infants, and fetal death. 1
• Reassure her that MAT is not "substituting one drug for another" but rather evidence-based medical treatment that improves outcomes for both her and her baby. 2
• Explain that neonatal opioid withdrawal syndrome (NOWS) may occur but is manageable by neonatology experts and is far preferable to the risks of continued illicit opioid use. 3, 4

Medication Selection and Initiation

Initiate buprenorphine as first-line treatment if available, as it offers greater accessibility and flexibility. 1 Reserve methadone for patients with severe opioid use disorder or history of IV drug use. 1

• Start buprenorphine at the lowest effective dose and titrate based on withdrawal symptoms and cravings, as proper dosing is essential to reduce respiratory depression risk. 3
• Do not attempt detoxification during pregnancy, as this dramatically increases relapse risk and can be fatal to both mother and fetus. 1

Critical Benzodiazepine Management

Address the benzodiazepine use with extreme caution, as concomitant use with buprenorphine can result in profound sedation, respiratory depression, coma, and death. 3

• Reserve concomitant prescribing of benzodiazepines and buprenorphine only when alternative treatment options are inadequate. 3
• If she continues occasional benzodiazepine use, prescribe the lowest effective buprenorphine dose and monitor closely for signs of respiratory depression and sedation. 3
• Counsel her that benzodiazepine use in late third trimester and during labor can cause floppy infant syndrome or marked neonatal withdrawal symptoms including apnea, cyanosis, hypotonia, and reluctance to suck. 5
• Screen for the source of benzodiazepines (prescribed vs. illicit) and coordinate with behavioral health to address underlying anxiety or other psychiatric conditions driving use. 6

Comprehensive Care Structure

Establish an interdisciplinary care team immediately, including addiction medicine specialists, behavioral health providers, and social services. 1, 6

• Screen for HIV, hepatitis C, hepatitis B, tuberculosis, and sexually transmitted infections, as these are more common in women with opioid use disorder. 1
• Evaluate and manage co-occurring psychiatric disorders and polysubstance use, as these are prevalent in this population. 6
• Address social stressors and environmental factors that may impact treatment adherence and outcomes. 6

Prenatal Monitoring Protocol

• Obtain at least one third-trimester growth ultrasound due to the association of opioid use disorder with low birth weight and small-for-gestational-age infants. 1
• Monitor for withdrawal symptoms and cravings throughout pregnancy, adjusting MAT doses as needed—pregnancy increases metabolic clearance, often requiring dose increases. 1, 2
• Provide frequent prenatal visits to monitor fetal growth and maternal complications. 2, 6

Labor and Delivery Planning

• Continue baseline MAT throughout labor and delivery—never discontinue or reduce doses during this period. 1
• Provide neuraxial analgesia early and do not undertreat pain during labor, as undertreating pain is a common pitfall. 1
• Ensure neonatology experts are available at delivery to manage potential NOWS, which may be life-threatening if not recognized and treated. 3

Postpartum Care

• Strongly encourage breastfeeding unless she is actively using illicit substances, as breastfeeding is beneficial and benzodiazepine levels in breast milk are generally low. 1, 5
• Offer long-acting reversible contraception immediately after delivery. 1
• Arrange close postpartum follow-up, as women are at high risk of overdose and death in the first year after delivery. 1

Common Pitfalls to Avoid

• Never attempt detoxification—this increases relapse risk and can be fatal. 1
• Do not underestimate the respiratory depression risk from combined buprenorphine and benzodiazepine use—this combination can be lethal. 3
• Do not reduce or discontinue MAT during labor—continue baseline doses and provide adequate pain control. 1
• Do not delay treatment initiation due to her ambivalence—pregnancy is an opportune time to engage her in treatment, and immediate action is critical. 6