Best Practices for Opioid Use Disorder Treatment in Pregnant Individuals

RESEARCH ANALYSIS

Best Practices for Opioid Use Disorder Treatment in Pregnant Individuals

Jesse Devlin, BS

Drexel University College of Medicine

SUMMARY POINTS

-       The American College of Obstetricians and Gynecologists recommends medication for opioid use disorder (MOUD) with behavioral therapy to reduce relapse risk and improve prenatal care compliance.

-       Physician-supervised detoxification during pregnancy is not recommended due to neonatal risks, which is supported by 1970s studies.

-       Studies show that buprenorphine reduces the risk of neonatal growth abnormalities and preterm birth compared to methadone.

-       Physician-supervised detoxification with behavioral health therapy may be a safe option to treat opioid use disorder in pregnant individuals, but further research on neonatal outcomes is needed.

ANALYSIS

Background

The American College of Obstetricians and Gynecologists (ACOG) recommends medication for opioid use disorder (MOUD) combined with behavioral therapy for pregnant individuals with opioid use disorder (OUD). This integrated approach has been shown to decrease relapse rates and improve compliance with prenatal care, thus reducing the risk of adverse obstetrical complications (1).

Detoxification is not recommended during pregnancy due to the potential risks involved. Two studies from the 1970s back this stance. They documented one stillbirth following methadone withdrawal in a pregnant woman with OUD and advised against detoxification unless the fetus could be closely monitored (2-3). Throughout the years, OUD in pregnancy has been on the rise, increasing more than fourfold from 1999 to 2014 alone (4). The rise of opioid use has consequently increased the cases of Neonatal Opioid Withdrawal Syndrome (NOWS). NOWS is a subset of Neonatal Abstinence Syndrome (NAS) diagnosed based on in utero opioid exposure and the presence of at least two common symptoms, such as excessive crying, fragmented sleep, tremors, increased muscle tone, and gastrointestinal dysfunction. The long-term effects of NOWS have not been extensively studied (5).

Around 2017, the medical community began questioning why physician-supervised detoxification was not considered a viable option for pregnant individuals with OUD. This study aims to analyze the best practices for treating opioid use disorder in this vulnerable population.

Findings

A 2016 study analyzed a collection of randomized controlled experiments and observational studies and found that there is a statistically significant decreased risk of growth abnormalities and preterm birth for buprenorphine compared with methadone. When looking at pregnant individual outcomes, there was no significant difference between individuals taking methadone vs. buprenorphine (6). A 2022 study confirmed a statistically significant decrease in preterm labor for individuals taking buprenorphine in comparison to methadone. However, the rate of preterm labor was still significantly higher than the national average (7). A 2024 study highlighted our knowledge gap when discussing longitudinal neurodevelopmental consequences on the neonate when exposed to MOUDs (8).

Another 2016 study demonstrated fast and slow detoxification from buprenorphine with behavioral health follow-up, denoted by Group 2 and Group 4 (Table 1), respectively. These groups had a statistically significant reduced rate of relapse and NAS occurrence in comparison to detoxification without a behavioral health follow-up (9).

Table 1. Demographics, gestational age at the time of detoxification, neonatal intensive care unit admission, and pregnancy outcome of the opiate detox study population. Bell J, Towers CV, Hennessy MD, Heitzman C, Smith B, Chattin K. Detoxification from opiate drugs during pregnancy. Am J Obstet Gynecol 2016;215(3):374.e1374.e3746. dio:10.10.16/j.ajog.2016.03.015

A 2020 study compared many factors in pregnant individuals in buprenorphine maintenance treatment, buprenorphine taper treatment, and the detoxification group. The results demonstrated that the detoxification group had a lower opioid relapse rate and fewer instances of NOWS. However, a limitation of this study was the small sample size and inability to randomize participants (10).

 Table 2. Treatment Outcome Group at Delivery and Dropout from Treatment, Opioid Relapse, Other Drug Use, Infant NOWS, and Women’s Childhood Sexual Abuse, N=55. Macfie J, Towers CV, Fortner KB, et al. Medication-assisted treatment vs. detoxification for women who misuse opioids in pregnancy: Associations with dropout, relapse, neonatal opioid withdrawal syndrome (NOWS), and childhood sexual abuse. Addict Behav Rep. 2020;12:100315. Published 2020 Nov 12. doi:10.1016/j.abrep.2020.100315

Discussion

We have limited options to treat OUD in pregnant individuals, and thus far, ACOG recommends MOUD with behavioral health therapy (1). Studies have shown that buprenorphine is associated with better neonatal outcomes through reduced preterm labor and decreased growth abnormalities (6,7). In addition, studies have suggested that physician-supervised detoxification may be a safe option for pregnant individuals (9,10). Regardless, behavioral therapy is recommended in combination with any of the above treatments (1,9,10). To best optimize care, it is imperative to continue fostering a safe environment for our patients to avoid stigma and ultimately improve outcomes for the pregnant individual–neonate dyad.

Despite the existing evidence supporting current treatment strategies, additional studies are needed to evaluate the neurodevelopment of neonates exposed to buprenorphine and methadone, as well as the safety and efficacy of detoxification during pregnancy. Equally important is the ongoing effort to reduce stigma and promote open, informed dialogue around opioid use and treatment during pregnancy.

REFERENCES

1.     Mascola MA, Borders AE, Terplan M. Opioid Use and Opioid Use Disorder in Pregnancy. American Society of Addiction Medicine. 2017;(711).

2.     Rementeriá JL, Nunag NN. Narcotic withdrawal in pregnancy: stillbirth incidence with a case report. Am J Obstet Gynecol. 1973;116(8):1152-1156. doi:10.1016/0002-9378(73)90953-8

3.     Zuspan FP, Gumpel JA, Mejia-Zelaya A, Madden J, Davis R. Fetal stress from methadone withdrawal. Am J Obstet Gynecol. 1975;122(1):43-46. doi:10.1016/0002-9378(75)90613-4

4.     Macfie J, Towers CV, Fortner KB, et al. Medication-assisted treatment vs. detoxification for women who misuse opioids in pregnancy: Associations with dropout, relapse, neonatal opioid withdrawal syndrome (NOWS), and childhood sexual abuse. Addict Behav Rep. 2020;12:100315. Published 2020 Nov 12. doi:10.1016/j.abrep.2020.100315

5.     Jilani SM, Jones HE, Grossman M, et al. Standardizing the Clinical Definition of Opioid Withdrawal in the Neonate. The Journal of Pediatrics. Published online December 2021. doi:https://doi.org/10.1016/j.jpeds.2021.12.021

6.     Zedler BK, Mann AL, Kim MM, et al. Buprenorphine compared with methadone to treat pregnant women with opioid use disorder: a systematic review and meta-analysis of safety in the mother, fetus, and child. Addiction. 2016;111(12):2115-2128. doi:10.1111/add.13462

7.     Abdelwahab M, Petrich M, Wang H, Walker E, Cleary EM, Rood KM. Risk factors for preterm birth among gravid individuals receiving buprenorphine for opioid use disorder. Am J Obstet Gynecol MFM. 2022;4(3):100582. doi:10.1016/j.ajogmf.2022.100582

8.     Dwivedi I, Haddad GG. Investigating the neurobiology of maternal opioid use disorder and prenatal opioid exposure using brain organoid technology. Front Cell Neurosci. 2024 May 15;18:1403326. doi: 10.3389/fncel.2024.1403326. PMID: 38812788; PMCID: PMC11133580.

9.     Bell J, Towers CV, Hennessy MD, Heitzman C, Smith B, Chattin K. Detoxification from opiate drugs during pregnancy. Am J Obstet Gynecol 2016;215(3):374.e1374.e3746. dio:10.10.16/j.ajog.2016.03.015

10.  Macfie J, Towers CV, Fortner KB, et al. Medication-assisted treatment vs. detoxification for women who misuse opioids in pregnancy: Associations with dropout, relapse, neonatal opioid withdrawal syndrome (NOWS), and childhood sexual abuse. Addict Behav Rep. 2020;12:100315. Published 2020 Nov 12. doi:10.1016/j.abrep.2020.100315