How would you manage a second trimester pregnant patient with daily heroin use and occasional benzodiazepine use, who is ambivalent about treatment but concerned about the baby's well-being?

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

Immediately initiate medication-assisted treatment (MAT) with methadone rather than buprenorphine for this patient, given the concurrent benzodiazepine use, as methadone may be more appropriate when there is concomitant use of benzodiazepines or other central nervous system depressants. 1

Initial Counseling Approach

• Use a nonjudgmental, supportive approach when discussing substance use, avoiding stigmatizing terms like "addict" and framing opioid use disorder as a treatable medical condition, not a moral failing 1
• Emphasize that continuing heroin use poses far greater risks than MAT, including stillbirth, poor fetal growth, preterm delivery, and fetal mortality 1, 2
• Explain that MAT is the standard of care during pregnancy and is safe, as it suppresses cravings and withdrawal while preventing illicit opioid use that leads to adverse pregnancy outcomes 1, 2
• Counsel that acute opioid withdrawal during pregnancy poses life-threatening risks to both mother and fetus, including spontaneous abortion and premature labor, making detoxification contraindicated 1, 3
• Discuss local legal implications of substance use during pregnancy, as 18 states define substance use as child abuse, so she understands potential consequences while emphasizing that treatment engagement protects both her and her baby 1

Medication-Assisted Treatment Selection

• Initiate methadone rather than buprenorphine as the first-line agent for this patient specifically because concurrent benzodiazepine use makes methadone more appropriate 1
• The FDA label explicitly states that buprenorphine treatment should not be categorically denied to patients taking benzodiazepines, as prohibiting treatment poses greater risk of morbidity and mortality from untreated opioid use disorder 4
• However, if buprenorphine is the only accessible option, it should not be withheld despite benzodiazepine use, but requires careful medication management 1
• The MOTHER trial demonstrated that both methadone and buprenorphine are safe in pregnancy, though buprenorphine-exposed infants required less treatment for neonatal opioid withdrawal syndrome (NOWS) and had shorter hospital stays 1

Benzodiazepine Management Strategy

• Do not attempt to rapidly taper or discontinue benzodiazepines during pregnancy, as abrupt cessation can precipitate seizures and harm both mother and fetus 3
• Develop a strategy to manage benzodiazepine use at MAT initiation through education about overdose risks when combining opioids, benzodiazepines, and alcohol 4
• If tapering benzodiazepines is pursued, use an extremely slow taper of 10% of the original dose per month, which may be better tolerated than the standard 10% per week taper 3
• Consider monitoring in a higher level of care for benzodiazepine taper if clinically indicated 4
• Optimize non-pharmacologic treatments for anxiety including psychoeducation, cognitive behavioral therapy, and mindfulness-based interventions before considering any taper 3

Comprehensive Care Structure

• Establish an interdisciplinary care team including addiction medicine specialists, maternal-fetal medicine, behavioral health providers, and social services 1, 2
• Screen for HIV, hepatitis B, hepatitis C, tuberculosis, and sexually transmitted infections, as these are more common in women with opioid use disorder 2, 5
• Connect her to psychosocial support services addressing social determinants of health such as housing or food insecurity 1
• Arrange prenatal consultation with anesthesia to discuss labor pain management expectations 1

Ongoing Prenatal Monitoring

• Continue MAT throughout pregnancy without attempting to wean or taper, as the goals are to suppress cravings and withdrawal while preventing illicit drug use 1, 2
• Monitor for withdrawal symptoms and adjust MAT doses as needed, recognizing that pregnancy increases drug metabolism and may require dose increases 1, 2
• Obtain at least one third-trimester growth ultrasound due to associations with low birth weight and small-for-gestational-age infants 2
• Use urine drug screening to monitor for prescribed and illicit benzodiazepines and confirm medication adherence 4

Delivery Planning

• Arrange delivery at a facility prepared to monitor, evaluate, and treat neonatal opioid withdrawal syndrome 1, 2
• Continue baseline MAT medication (methadone or buprenorphine) throughout labor and delivery to treat the underlying disorder and prevent acute withdrawal 1
• Consider dividing the maintenance medication dose into 2-3 doses during labor to improve pain control 1
• Encourage neuraxial labor analgesia (epidural) early in labor, as this is highly effective in opioid-dependent women 1, 2
• Avoid opioid agonist/antagonists like nalbuphine or butorphanol, as these can precipitate withdrawal 1, 3

Postpartum Management

• Strongly encourage breastfeeding unless actively using illicit substances, as benefits outweigh risks when on stable MAT 2
• Offer long-acting reversible contraception immediately after delivery 2
• Arrange close postpartum follow-up with identified primary care and addiction medicine providers, as women are at high risk of overdose and death in the first year after delivery 1, 2
• Plan for multimodal postpartum pain management starting with non-opioid approaches, though additional systemic opioids may be necessary 1, 3

Critical Pitfalls to Avoid

• Never attempt detoxification, rapid opioid taper, or ultrarapid detoxification under anesthesia during pregnancy due to substantial risks including maternal and fetal death 1, 3
• Do not undertreat pain during labor—continue baseline MAT and provide adequate neuraxial analgesia 1, 2
• Avoid creating barriers to treatment, as denying or delaying MAT poses greater risk of morbidity and mortality from untreated opioid use disorder 4
• Do not use arbitrary dose caps of buprenorphine as a strategy to address benzodiazepine use, as there is no evidence supporting this approach 4