Pregnancy and opioids: treatment and the newborn

A twenty-six-year-old woman comes to her first prenatal visit at sixteen weeks of gestation. After a few minutes of conversation, she says that she has been using opioids bought outside the pharmacy for two years and that she tried to stop on her own twice, without success. She asks, in a low voice, whether she needs to stop now "so as not to harm the baby" and whether they will take the child away from her after delivery. The team has few minutes and many decisions ahead. This text uses opioid use in pregnancy as a scenario for clinical reasoning: why maintaining or starting an opioid agonist is usually the central choice, why withdrawal is not the standard approach, how to think about the choice between buprenorphine and methadone in this context and how newborn care changed with the Eat, Sleep, Console approach. The scene and the examples throughout the text are fictional and were written for teaching.

NEXO is a daily medical diagnosis game: one clinical case a day, up to six progressive clues, and ICD-10 proximity feedback across five levels.

The text also avoids being a dosing protocol. Induction, adjustments throughout pregnancy, analgesia in labor and neonatal management follow the guidelines and protocols of each service, with obstetrics, addiction medicine and pediatrics. The focus here is the way of thinking: what questions to ask, how to weigh risks for the pregnant woman and for the baby and how to keep the person in care. If you play the case of the day on NEXO, you will recognize the move: the clue that seems to call for a quick approach sometimes calls for a more careful one.

Key points

• In pregnancy, treatment with an opioid agonist, buprenorphine or methadone, is the approach recommended by the main guidelines for opioid use disorder.
• Supervised withdrawal during pregnancy has a low completion rate and a high rate of return to use, according to a systematic review, and is therefore not the standard choice.
• Buprenorphine and methadone are accepted options; studies suggest slightly more favorable neonatal outcomes with buprenorphine, and the choice is shared.
• The Eat, Sleep, Console approach reduced the time until the newborn was ready for discharge in a randomized trial, without increasing specified adverse outcomes.
• The first year after delivery is a period of higher risk of overdose, and continuity of treatment is part of care.

Why pregnancy changes the reasoning

Pregnancy is often a time of great motivation for change. At the same time, it brings fear, guilt and the worry of losing custody of the child, which can push the person away from prenatal care. The American College of Obstetricians and Gynecologists describes pregnancy as an important opportunity to identify and treat opioid use and recommends treatment with an opioid agonist for opioid use disorder in pregnancy (ACOG, 2017).

The World Health Organization published guidelines in 2014 for identifying and managing substance use in pregnancy, with guidance on asking about substance use at every visit, offering brief interventions and encouraging treatment with an opioid agonist for pregnant women with opioid dependence (WHO, 2014). Both documents converge on one idea: the goal is to stabilize the pregnant woman and protect the pregnancy, and the agonist is the main tool.

Asking all pregnant women, and not only those who "seem" to be at risk, is a point in the reasoning that deserves emphasis. When the question depends on the professional's impression, it follows stereotypes of class, color and appearance, and many pregnant women miss the chance to speak. A question asked routinely, with the same sentence for everyone, reduces this bias and makes the answer less threatening. A simple sentence is usually enough: "We ask all pregnant women about alcohol, tobacco, medicines and other substances, because this helps us take better care of you and the baby." The same applies to the use of several substances at the same time: tobacco, alcohol, benzodiazepines and stimulants change the risk and the care, and the conversation about opioids opens space to ask about them.

Fear as a barrier

The question in the opening scene, "will they take my child away from me?", is a clinical clue. It shows what can push a person away from care. Answering honestly about local rules, explaining that treatment usually improves outcomes and involving social work with care are part of the approach. The language used in the medical record and in the conversation matters a great deal here, as the post on stigma and language shows. Some word choices help:

• Using "pregnant woman with opioid use disorder" instead of labels like "user".
• Using "newborn exposed to opioids" instead of "addicted baby".
• Using "on buprenorphine treatment" instead of "replacing one drug with another".
• Using "neonatal abstinence syndrome" as the diagnosis, without a tone of blame.

Why withdrawal is not the default choice

The intuition of many professionals, and of many pregnant women, is that the best course would be to stop all opioids as soon as possible. The evidence points in another direction. Mishka Terplan and colleagues systematically reviewed opioid withdrawal during pregnancy and concluded that the evidence does not support withdrawal as a recommended treatment, because of the low completion rate, the high rate of return to use and the limited data on outcomes after delivery (Terplan and colleagues, 2018).

Return to use after withdrawal carries a particular risk: tolerance drops, and the dose used before can cause overdose. In pregnancy, overdose threatens two lives at once. That is why clinical reasoning weighs the agonist as a way to stabilize the pregnant woman, reduce the use of non-prescribed opioids and bring the person closer to prenatal care.

When the person asks to stop. Some pregnant women ask for withdrawal even after talking about the risks. Shared decision making includes hearing the reason, explaining the evidence and, if the person keeps the choice, offering close follow-up, with the door open to start the agonist at any time. The post on harm reduction beyond all or nothing helps to think through these choices without turning care into an ultimatum.

Buprenorphine or methadone in pregnancy

The choice between buprenorphine and methadone follows the general principles of shared decision making, laid out in the post on buprenorphine or methadone. In pregnancy, some specific points enter the conversation.

The MOTHER trial, by Hendrée Jones and colleagues, randomized pregnant women with opioid dependence to methadone or buprenorphine. Newborns exposed to buprenorphine needed less morphine, had shorter hospital stays and shorter treatment for neonatal abstinence syndrome, and the authors concluded that buprenorphine is an acceptable treatment in pregnancy (Jones and colleagues, 2010). The proportion of newborns who needed treatment and the peak abstinence score were similar in both groups (Jones and colleagues, 2010). In MOTHER, 28 of 86 pregnant women in the buprenorphine group left treatment, against 16 of 89 in the methadone group (Jones and colleagues, 2010), a finding that weighs on the individual choice.

Elizabeth Suarez and colleagues analyzed a large cohort of pregnant women in the United States and found a lower risk of adverse neonatal outcomes with buprenorphine than with methadone, with a similar risk of adverse maternal outcomes (Suarez and colleagues, 2022).

The table sums up points that often enter the decision, always adjusted to the case and to what the service offers.

Point	Buprenorphine	Methadone
Neonatal outcomes	Less morphine and shorter hospital stay for the newborn in MOTHER; lower risk of preterm birth and low birth weight in a large cohort (Suarez and colleagues, 2022)	Option with long clinical experience
Starting treatment	Requires planning to avoid precipitated withdrawal	Start without risk of precipitated withdrawal
Retention	In MOTHER, 28 of 86 left treatment, against 16 of 89 on methadone	Dispensing structure may favor retention
Access	Outpatient prescription in many countries	Often depends on a specialized service
Preference of the pregnant woman	Previous experiences and routine weigh heavily	Previous experiences and routine weigh heavily

Those already in treatment

For a pregnant woman who is already stable on methadone or buprenorphine, the approach is usually to keep the medication that works. Switching agonists during pregnancy carries risks of destabilization, and the decision is individual. Doses often need adjustment throughout pregnancy because of changes in metabolism, and this adjustment follows the service protocol.

Starting buprenorphine

When the choice is to start buprenorphine in someone who uses potent opioids, the risk of precipitated withdrawal needs to be part of the planning. The post on precipitated withdrawal when starting buprenorphine explains the reasoning behind induction, which also applies in pregnancy, with extra attention to discomfort and safety.

Care during pregnancy and delivery

Treatment of opioid use disorder is one part of care. The pregnant woman may need testing for infections, mental health care, social support and monitoring of other substances, such as tobacco and alcohol. ACOG recommends coordinating prenatal care with treatment of the dependence and planning labor analgesia in advance (ACOG, 2017).

Labor analgesia

A pregnant woman on agonist treatment feels pain like anyone else and often needs higher doses of analgesics because of tolerance. Keeping the baseline agonist and planning analgesia with anesthesia prevents pain from being undertreated out of fear. Talking about this before delivery helps reduce anxiety and mistrust. Some teams record on the prenatal card the agonist in use, the dose and the contact of the prescribing service, so that the on-call team at delivery has the information without relying on the memory of a woman in labor. Agreeing in advance who will prescribe the agonist during the maternity stay prevents missed doses, which can cause withdrawal precisely when the woman needs to be comfortable to care for the baby. Cesarean section and other interventions follow the usual obstetric indications, and postoperative analgesia may need similar adjustments.

Breastfeeding

WHO and ACOG guidelines encourage breastfeeding for women who are stable on opioid agonist treatment, unless there are specific contraindications, such as use of other substances or HIV infection (WHO, 2014; ACOG, 2017). Breastfeeding is also part of the non-pharmacological care of the newborn, as we will see next.

The newborn: neonatal abstinence syndrome

Newborns exposed to opioids during pregnancy may present neonatal abstinence syndrome, also called neonatal opioid withdrawal syndrome. The American Academy of Pediatrics describes signs such as irritability, tremors, excessive crying, difficulty feeding, short sleep and gastrointestinal symptoms, and recommends non-pharmacological care as the basis of management (Patrick et al., 2020).

Elisha Wachman and colleagues reviewed the diagnosis and treatment of the syndrome and showed that much of the evidence came from small or low-quality studies, focused on intermediate outcomes such as need for pharmacological treatment and length of stay (Wachman et al., 2018). This gap helps explain why management has changed so much in the last decade.

Before attributing the signs to withdrawal, the reasoning includes the differential. Irritability, tremor, difficulty feeding and excessive crying also appear in infection, hypoglycemia, hypocalcemia, neonatal hyperthyroidism and neurological problems. A history of exposure increases the probability of withdrawal, but a child with fever, lethargy or rapid worsening calls for investigation. Time of onset is also a clue: it depends on the half-life of the opioid of exposure, and a picture that departs from the expected pattern deserves another explanation. Remembering that more than one substance may be involved, including tobacco and benzodiazepines, helps interpret signs that do not fit.

The Finnegan score

For decades, assessment relied on the Finnegan score, published in 1975, which adds points for various signs and guides the start and adjustment of morphine (Finnegan et al., 1975). The score helped standardize assessment, and it also drew criticism: many items, examiner influence and a tendency to treat with medication newborns who could improve with non-pharmacological care.

Eat, Sleep, Console: another clinical question

The Eat, Sleep, Console approach changes the question. Instead of adding up signs, the team asks whether the newborn can feed well, sleep for an adequate period and be consoled in a short time. If the answer is yes, the focus stays on non-pharmacological care; if it is no, the team first intensifies that care and, if necessary, considers medication.

Matthew Grossman and colleagues described the implementation of the approach in a hospital and argued for a reassessment of the management of the syndrome (Grossman et al., 2017). The ESC-NOW trial, by Leslie Young and colleagues, randomized hospitals to the Eat, Sleep, Console approach or to usual care. The approach significantly reduced the number of days until the newborn was ready for discharge, without increasing specified adverse outcomes (Young et al., 2023).

Non-pharmacological care usually includes simple measures, applied consistently:

1. Rooming-in, with the baby in the mother's room.
2. Skin-to-skin contact and frequent holding.
3. A calm environment, with little light and little noise.
4. Breastfeeding, when indicated, or feeding on demand.
5. Involvement of the family as part of the care team.

The reasoning behind the change. The shift from the score to function shows an important point of clinical reasoning: the question we ask defines the answer we find. A score with many items tends to detect "abnormalities" in almost every baby. A question about function leads the team to look at what matters to the child and the family. The mother stops being only the source of exposure and becomes a central part of treatment. For the nursing team, the change also alters the routine: instead of scoring signs every few hours, conversation with the family about how the baby fed, slept and calmed down starts to guide decisions, and the family gains an active role in care.

After delivery: the period of greatest risk

Care continues after delivery. Davida Schiff and colleagues studied fatal and nonfatal overdoses among pregnant and postpartum women in Massachusetts and showed that the year after delivery is a vulnerable period for women with opioid use disorder, with a need for longitudinal support (Schiff et al., 2018).

This period brings together sleep deprivation, changes in routine, the end of prenatal follow-up and, sometimes, a reduction of the agonist for fear of affecting the baby. The transition from obstetric care to continuous care needs to be planned before discharge from the maternity ward.

Discharge of the newborn usually involves social services and, in some places, mandatory notifications. Clinical reasoning requires that these steps be taken with transparency and with equal criteria for all families. Explaining to the mother what will be assessed, who takes part and what she can expect reduces fear and preserves the bond with the team. Treatment with an agonist is, in itself, a sign of care for the pregnancy, and the record needs to reflect this clearly. When the report in the medical record describes the mother by her diagnosis and treatment, and not by labels, the next team tends to make fairer decisions.

What to agree on at discharge from the maternity ward

Some questions help organize discharge:

• Who will prescribe the agonist in the coming weeks?
• Was the dose reviewed after delivery, according to the service protocol?
• Does the family have naloxone and know how to use it?
• Does the postpartum woman have follow-up for mental health and contraception?
• Does the newborn have a scheduled pediatric appointment?

Biases that get in the way of care

Pat Croskerry describes cognitive shortcuts that affect clinical decisions (Croskerry, 2003). In the care of pregnant women with opioid use disorder, some of them appear often. Affective bias makes the team react to the history of use with judgment, and decisions then reflect that judgment. All-or-nothing thinking leads to preferring withdrawal, even when the evidence points to the agonist. Attributing any sign in the newborn to withdrawal can delay the diagnosis of other causes, such as infection or hypoglycemia. The post about affective bias explains how the professional's emotions enter the reasoning.

The topic also appears in assessments and in resident training, and the post about how substance use is tested organizes the main concepts in a comparative way.

How NEXO helps train this reasoning

In NEXO, the case of the day is fictional, with a real clinical presentation and up to six progressive clues. You propose a diagnosis by searching for the ICD-10 code and receive proximity feedback on five levels, which shows whether the guess landed on the exact code, the same category, the same group, the same chapter or a different chapter. This format speaks to the theme of this text: a sign such as irritability in a newborn can have several explanations, and the feedback shows whether you considered the alternatives.

To use the case of the day as training, try three habits. Before each guess, ask what different explanations could produce the same clue. When the answer seems obvious, write down the second most likely hypothesis. After the result, note which clue you interpreted in a hurry.

Three exercises with cases

Broaden the differential. In a case of an irritable newborn, list causes beyond withdrawal, such as infection, hypoglycemia and metabolic disorders.

Rewrite the conversation. Take a chart sentence with a label, such as "drug-using mother", and rewrite it with person-centered language.

Plan the transition. For a fictional postpartum woman in treatment, write what needs to be agreed before discharge.

The post about case-based learning shows why training with cases fixes this type of decision, and the post about differential diagnosis with clues shows how to broaden the hypotheses with each new piece of information.

The limits on using the game are described on the NEXO economy page. If you research the teaching of clinical reasoning, the page for researchers explains how to get in touch. Professionals who write or review cases find information on curation and on creators, and institutions can learn about the proposal on the partnerships page.

Frequently asked questions

Should pregnant women with opioid use disorder stop use at once?

The recommendation of the main guidelines is treatment with an opioid agonist, buprenorphine or methadone. Withdrawal has a low completion rate and a high rate of return to use (Terplan et al., 2018).

Is buprenorphine safe in pregnancy?

The MOTHER trial concluded that buprenorphine is an acceptable treatment in pregnancy: newborns needed less morphine and shorter hospitalization and treatment, with a proportion treated similar to that of methadone (Jones et al., 2010).

Can a pregnant woman in agonist treatment breastfeed?

She can, in most situations. WHO and ACOG guidelines encourage breastfeeding for women who are stable in treatment, unless there are specific contraindications.

What is the Eat, Sleep, Console approach?

It is a way of assessing the newborn by function: whether the baby feeds, sleeps and is consoled. In the ESC-NOW trial, it reduced the time to discharge (Young et al., 2023).

Does every baby exposed to opioids need morphine?

The need for medication is individual. Non-pharmacological care is the foundation, and medication comes in when that care is insufficient.

Why does the postpartum period deserve special attention?

The year after birth concentrates the risk of overdose, and continuity of agonist treatment protects the woman (Schiff et al., 2018).

Final checklist

• I asked about substance use with non-judgmental language.
• I offered opioid agonist treatment as the main approach.
• I discussed buprenorphine and methadone with the pregnant woman, considering preference and access.
• I planned labor analgesia in advance.
• I arranged rooming-in and non-pharmacological care for the newborn.
• I arranged for continued agonist therapy and naloxone before discharge.
• I scheduled follow-up for the postpartum woman and the baby.

Want to practice your reasoning with progressive clues? Play today's case.

References

1. American College of Obstetricians and Gynecologists. Committee Opinion No. 711: Opioid Use and Opioid Use Disorder in Pregnancy. Obstet Gynecol. 2017. PMID 28742676.
2. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003. PMID 12915363.
3. Finnegan LP, Connaughton JF Jr, Kron RE, Emich JP. Neonatal abstinence syndrome: assessment and management. Addict Dis. 1975. PMID 1163358.
4. Grossman MR, Osborn RR, Berkwitt AK. Neonatal Abstinence Syndrome: Time for a Reappraisal. Hosp Pediatr. 2017. PMID 28137921.
5. Jones HE, Kaltenbach K, Heil SH, et al. Neonatal abstinence syndrome after methadone or buprenorphine exposure. N Engl J Med. 2010. PMID 21142534.
6. World Health Organization. Guidelines for the identification and management of substance use and substance use disorders in pregnancy. 2014. who.int.
7. Patrick SW, Barfield WD, Poindexter BB, et al. Neonatal Opioid Withdrawal Syndrome. Pediatrics. 2020. PMID 33106341.
8. Schiff DM, Nielsen T, Terplan M, et al. Fatal and Nonfatal Overdose Among Pregnant and Postpartum Women in Massachusetts. Obstet Gynecol. 2018. PMID 29995730.
9. Suarez EA, Huybrechts KF, Straub L, et al. Buprenorphine versus Methadone for Opioid Use Disorder in Pregnancy. N Engl J Med. 2022. PMID 36449419.
10. Terplan M, Laird HJ, Hand DJ, et al. Opioid Detoxification During Pregnancy: A Systematic Review. Obstet Gynecol. 2018. PMID 29630016.
11. Wachman EM, Schiff DM, Silverstein M. Neonatal Abstinence Syndrome: Advances in Diagnosis and Treatment. JAMA. 2018. PMID 29614184.
12. Young LW, Ounpraseuth ST, Merhar SL, et al. Eat, Sleep, Console Approach or Usual Care for Neonatal Opioid Withdrawal. N Engl J Med. 2023. PMID 37125831.