The use of buprenorphine for Opioid Use Disorder (OUD) is widely supported and recommended for pregnant individuals. Major medical organizations, including the American College of Obstetricians and Gynecologists (ACOG) and the Substance Abuse and Mental Health Services Administration (SAMHSA), endorse continuing or starting this treatment during pregnancy. Buprenorphine is a partial opioid agonist, meaning it activates opioid receptors but to a lesser degree than full agonists like heroin or methadone, which helps manage withdrawal and reduce cravings. Treatment with buprenorphine is part of a comprehensive approach known as Medication-Assisted Treatment (MAT), which is the standard of care for OUD in pregnancy. The known risks associated with untreated OUD far outweigh any potential risks from the medication itself.
Risks of Untreated Opioid Use Disorder During Pregnancy
Stopping opioid maintenance medication abruptly or failing to seek treatment for OUD poses significant dangers to both the pregnant individual and the developing fetus. Untreated OUD creates cycles of intoxication and withdrawal, which can cause severe stress and instability in the mother’s body. This instability heightens the risk of complications such as miscarriage, preterm labor, and placental abruption.
Relapse to illicit opioid use is a major concern when treatment is stopped, dramatically increasing the risk of overdose, which is a leading cause of maternal death in the postpartum period. Illicit drug use also introduces inconsistent drug exposure to the fetus, potential infectious diseases like HIV and hepatitis C from injection use, and poor maternal nutrition and prenatal care. These factors collectively increase the likelihood of fetal growth restriction, low birth weight, and stillbirth. The controlled, consistent dosing provided by buprenorphine stabilizes the maternal environment, allowing the person to engage in consistent prenatal care and focus on recovery.
Standard Treatment Protocols and Formulation Guidance
Opioid agonist therapy is the established standard of care for OUD during pregnancy, and both buprenorphine and methadone are approved options. When comparing the two, buprenorphine has shown superior neonatal outcomes, often resulting in less severe Neonatal Opioid Withdrawal Syndrome (NOWS) and shorter hospital stays for the infant compared to methadone. The partial agonist properties of buprenorphine make it a safer option regarding the risk of respiratory depression and overdose compared to full agonists.
Buprenorphine is available as monotherapy and as a combination product with naloxone. Historically, buprenorphine monotherapy was preferred in pregnancy to avoid any theoretical exposure of the fetus to naloxone, the opioid antagonist component. However, recent clinical data suggest the buprenorphine/naloxone combination is also safe and effective, showing similar maternal and neonatal outcomes to monotherapy. The combination formulation is often preferred in the general population due to its lower risk of misuse or diversion. Treatment during pregnancy requires close coordination between the OUD treatment provider and the obstetrician to ensure personalized care. Due to changes in the mother’s metabolism and body weight during pregnancy, the daily dosage of buprenorphine may need to be adjusted, sometimes requiring higher or more frequent doses to maintain effectiveness.
Understanding Neonatal Opioid Withdrawal Syndrome
Neonatal Opioid Withdrawal Syndrome (NOWS), formerly known as Neonatal Abstinence Syndrome (NAS), is an expected and treatable condition that occurs in newborns exposed to opioids in the womb, including buprenorphine. This syndrome is a physical dependence on the opioid consistently present in utero, not a sign of addiction. Symptoms typically manifest within the first one to three days after birth, though they can be delayed up to a week.
Common signs of withdrawal include:
- Nervous system irritability, such as tremors, hyperactivity, and high-pitched crying.
- Gastrointestinal issues like vomiting and diarrhea.
- Poor feeding and trouble sleeping.
- Autonomic symptoms like frequent yawning or sweating.
Treatment begins with non-pharmacological interventions, which are the first line of defense for all exposed infants. These gentle measures include skin-to-skin contact, frequent small feedings, and a quiet environment to minimize stimulation. If a baby cannot eat, sleep, and be consoled effectively, medication such as oral morphine or phenobarbital may be used to manage symptoms and is slowly weaned over time. The long-term developmental outcomes for infants who experience NOWS and are treated appropriately are generally positive.
Postpartum Management and Breastfeeding
The postpartum period is a time of high vulnerability for relapse, with overdose being a significant cause of maternal mortality. Continuing MAT with buprenorphine is recommended postpartum to sustain recovery and stability. Healthcare providers must proactively plan for pain management during labor and delivery, as standard doses of buprenorphine may not be sufficient to control acute pain.
Breastfeeding is encouraged for mothers stable on buprenorphine, as the medication transfers into breast milk in very low, clinically insignificant amounts. The benefits of breastfeeding, including nutritional advantages and soothing comfort, may help lessen the severity of NOWS symptoms and shorten the baby’s hospital stay. Mothers should be monitored for signs of excessive infant drowsiness or feeding difficulties, though these issues are uncommon given the poor oral absorption of buprenorphine by the infant.