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Opioid Use During Pregnancy: Risk Factors, Side Effects, and Treatment

By Claire Wilcox, MD
Nov 03, 2021

Opioid misuse during pregnancy is dangerous to both the fetus and mother. Despite this, illicit opioid use in pregnant women is on the rise.

According to available data, opioid use disorder (OUD) rates in pregnant women have increased 130% from 2010 to 2017.[1] In addition to this, between 1-2% of women reported misuse of prescription opioid pain relievers in 2019.[2]

In this article, we will cover the risks associated with opioid use, misuse, and OUD during pregnancy. We will also discuss why Medication for Addiction Treatment (MAT) is the best treatment approach and what medications are commonly prescribed.

Risks Associated with Opioid Use During Pregnancy

There are numerous risks and consequences of opioid misuse during pregnancy:

  • Impaired placenta function (from repeated cycles of withdrawal from opioids) 
  • Miscarriage
  • Stunted growth 
  • Preterm labor
  • Stillbirth
  • Birth defects
  • Fetal convulsions
  • Fetal death 
  • Maternal death 
  • Rehospitalizations within 30 days of birth and longer hospital stays after birth 
  • Infection (HIV, hepatitis) and malnutrition secondary to high-risk behaviors and poor prenatal care
  • Neonatal Abstinence Syndrome

What Is Neonatal Abstinence Syndrome?

Neonatal Abstinence Syndrome (NAS) refers to the opioid withdrawal syndrome that occurs in the newborn when the mother has been taking opioids daily or has OUD before giving birth.

When the fetus is exposed to opioids during pregnancy at high doses, it will develop a tolerance to opioids and a susceptibility to withdrawal symptoms when the opioid blood levels drop upon delivery.[2]

NAS is treated in the hospital with supportive care and morphine.[3] Signs of NAS occur within 72 hours after birth and include the following symptoms:

  • Tremors/trembling
  • Diarrhea
  • Fever
  • Irritability
  • High pitched crying
  • Yawning/stuffy nose
  • Troubles sleeping
  • Increased sweating
  • Hyperactive reflexes
  • Seizures
  • Difficulty sucking and feeding
  • Dehydration

An infant with NAS might have a higher risk of later developmental delay, language impairment, and educational disabilities. However, these claims are still unconfirmed by larger studies.

Opioid Use Disorder Treatments During Pregnancy

Opioid use disorder is a diagnostic term that helps clinicians identify people whose opioid use has spiraled out of control. Colloquial terms for OUD include “opioid addiction” and “opioid dependency.” 

All patients with OUD should seek treatment with MAT throughout their pregnancy to block cravings and prevent relapse. Simply going through detox and getting counseling is not enough since studies consistently show better fetal and maternal outcomes with MAT. 

MAT is the standard of care, and methadone and buprenorphine are endorsed for the treatment of pregnant women with OUD by the American College of Obstetricians & Gynecologists (ACOG) and the American Society of Addiction Medicine (ASAM).[4] 

There are three primary types of medications used in MAT: 

  • Methadone
  • Buprenorphine-containing medications
  • Naltrexone-containing medications

Methadone Therapy During Pregnancy

Similar to morphine, fentanyl, and heroin, methadone is a full opioid agonist that activates the opioid receptor. For over half a century, methadone has been used for the treatment of OUD. It is longer-acting than most opioids which means it stabilizes blood levels and prevents withdrawal. 

Methadone dispensing during OUD treatment is highly structured, and clinics are required to have special licensing, which minimizes abuse and diversion.

Studies show that methadone treatment of pregnant women with OUD reduces craving, relapse, HIV and hepatitis C infection rates, and legal problems. It also reduces the risk of death by overdose compared to no treatment or psychosocial treatment alone. It also improves perinatal care, reduces NAS risk, and leads to higher gestational age, weight, and head circumferences.

One negative of methadone is that the infant can still experience NAS upon delivery, albeit to a lesser degree than that seen with abused opioids.[5] 

Despite this, methadone is still better for pregnant women than detoxification and psychosocial treatment alone. It prevents the repeated cycles of intoxication and withdrawal associated with opioid misuse. 

On the other hand, the NAS is worse in infants whose mothers are treated with methadone compared to buprenorphine. 

Buprenorphine Therapy During Pregnancy

Buprenorphine is a partial agonist at the opioid receptor. Like methadone, it can block cravings and withdrawal symptoms and prevent relapse. 

However, buprenorphine has an additional safety advantage over methadone. At higher doses, it has a ceiling effect, meaning the opioid agonist effect doesn’t increase past a certain dose. As a result, it is much harder to overdose on buprenorphine than methadone and other full agonists.

Buprenorphine also stabilizes maternal and fetal levels of opioids and prevents perinatal withdrawal, similar to methadone. It links mothers to perinatal care, reduces infection risk, reduces NAS severity, and improves maternal, pregnancy, fetal, and infant outcomes.[5] 

Although NAS can occur upon delivery, it is less severe than the NAS seen with maternal use of illicit opioids or methadone. Other fetal outcomes might be better with buprenorphine compared to methadone, too.

Suboxone vs. Subutex Therapy During Pregnancy

Suboxone and Subutex are both medications that contain buprenorphine. The main difference between the two is that Suboxone has an additional component called naloxone, which discourages misuse.

Until recently, Subutex was used in pregnant women almost exclusively because of concerns that naloxone might cross the placenta and cause adverse effects. 

However, more recent studies show that very little placental transfer occurs and that Suboxone might be as safe or safer for the fetuses and infants than either methadone or Subutex.

Naltrexone Therapy During Pregnancy

Naltrexone, often given in a monthly injectable form, is the third medication sometimes used to prevent relapse in OUD because it blocks craving and prevents relapse. Unlike buprenorphine and methadone, naltrexone (Vivitrol) is an opioid receptor blocker, not an agonist. 

Until recently, naltrexone was not a recommended treatment for pregnant women with OUD, except for those already taking naltrexone for OUD before they got pregnant.  

Although still not standard of care, it is increasingly being used off-label for OUD treatment in pregnancy, and more research into its safety and efficacy is underway. So far, rates of adverse effects from naltrexone or Vivitrol compared to methadone or buprenorphine and untreated OUD appear to be similar.

OUD Treatments to Avoid While Pregnant

Of the three OUD medication treatments, the only one that should be avoided is no treatment at all. Study after study shows that MAT is better for the mother and the fetus than no MAT, i.e., 12-step programs or counseling alone. Relapse rates without MAT are high, and repeated cycles of withdrawal and intoxication associated with untreated OUD are dangerous.

That said, all three kinds of medications used during MAT can cross the placenta and are considered “Class C” by the FDA. This means that it is still unknown whether the medication has direct adverse effects on the fetus. 

Bicycle Health's Treatment Options for OUD in Pregnancy

Untreated OUD in pregnancy is dangerous, and guidelines encourage all pregnant mothers to take MAT. 

If you have questions about whether Medication for Addiction Treatment (MAT) is a right fit for you, schedule a time to speak with one of our MAT professionals, or call us today at (844) 943-2514.

Image by Free-Photos from Pixabay

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Citations

1. Hirari AH, Ko JY, Owens PL et al. Neonatal Abstinence Syndrome and Maternal Opioid-Related Diagnoses in the US, 2010-2017. JAMA 2021 325(2):146-155. doi:10.1001/jama.2020.24991   

2. Ko JY, D’Angelo DV, Haight SC, et al. Vital Signs: Prescription Opioid Pain Reliever Use During Pregnancy — 34 U.S. Jurisdictions. MMWR Morb Mortal Wkly Rep 2019 69:897–903. DOI:http://dx.doi.org/10.15585/mmwr.mm6928a1external icon.

3. McQueen K, Murphy-Oikonen Neonatal Abstinence Syndrome. N Engl J Med 2016 375:2468-2479 DOI: 10.1056/NEJMra1600879

4. American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice with committee members Mascola MA and Borders AE; American Society of Addiction Medicine member Terplan M. Opioid Use Disorder in Pregnancy. ACOG COMMITTEE OPINION: Number 711 • August 2017 https://www.acog.org/-/media/project/acog/acogorg/clinical/files/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy.pdf

5. Jones HE, Kaltenbach K, Heil SH, Stine SM, Coyle MG, Arria AM, O’Grady KE, Selby P, Martin PR, Fischer G Neonatal Abstinence Syndrome after Methadone or Buprenorphine Exposure New England Journal of Medicine 2010 363(24):2320-2331. DOI: 10.1056/NEJMoa1005359

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