OpenMFM   Patient & Provider

Buprenorphine Initiation
& Maintenance
in Pregnancy

Clinical guide with patient counseling points

Chukwuma Onyeije, MD, FACOG  |  Maternal-Fetal Medicine
Primary source: Dartmouth-Hitchcock CARPP guidance; reviewed against ACOG, SMFM, and SAMHSA framing

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01 — Initial Assessment

Diagnosis
Confirm OUD by DSM-5 criteria supplemented by urine drug testing.

Inventory all current and past substances; document prior SUD treatment history.
Co-morbidities
Screen for depression, anxiety, and PTSD.

Assess social and environmental factors; screen for intimate partner violence.
Physical Exam
Examine for sequelae of substance use.

Assess facilitators and barriers to pharmacotherapy.
Laboratory
CBC, LFTs, renal function, Hep C, HIV, STIs, TB.

Offer Hep A & B testing and vaccination when appropriate.
Patient-facing anchor: medication treatment is safer than repeated opioid use and withdrawal, and it works best with behavioral and social support.
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02 — Treatment Setting Selection

Setting Indication Features
Office-Based Low complexity, stable social support, low diversion risk Buprenorphine or methadone; flexible scheduling
Intensive Outpatient (IOP) Moderate complexity; needs structured counseling More frequent visits; intensive psychosocial support
Specialty OTP Complex patients; daily supervised dosing needed Daily methadone or buprenorphine; highest structure
Inpatient / Residential Failed less intensive options; severe complexity 24-hour care; reserved for most complex cases
Shared decision-making: consider past treatment history, psychiatric co-morbidities, social factors, and diversion risk. Methadone remains an established standard of care in pregnancy.
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03 — Informed Consent & Treatment Agreement

The treatment agreement clarifies expectations for both practitioner and patient, and provides structure for effective monitoring. It must be reviewed and signed by both parties.
Single prescribing practice
Single designated pharmacy
PDMP use acknowledged
Toxicology screens agreed
Pill / film counts on request
Authorization to communicate with other providers
Consent must include risks and benefits of buprenorphine compared to methadone and other treatment options.
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04 — Induction Timing

Preventing Precipitated Withdrawal

≥12
COWS Score Required
Before First Dose
Short-acting opioids
heroin, hydrocodone, oxycodone IR
12 – 16 hours
Intermediate-acting
OxyContin
17 – 24 hours
Methadone
30 – 48 hours
Failure to wait for adequate withdrawal is the most common cause of precipitated withdrawal — a severe and distressing complication.
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05 — Induction Setting in Pregnancy

Office / Home Induction
GA < 23 weeks without complicating factors.

Preferred if patient has prior buprenorphine experience.
Inpatient / In-Clinic
GA ≥ 23 weeks, acute illness, polysubstance use, or long-acting opioids.

Also indicated for adherence concerns or obstetric co-morbidities.
Women already on a stable, known dose of buprenorphine may receive a prescription without formal induction.
In-office induction is generally preferred over home induction during pregnancy.
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06 — Induction Protocol

Step 1
Confirm COWS ≥ 12
›
Step 2
Administer 4 mg SL
(2 mg if not physically dependent)
›
Step 3
Observe 45–60 min
Reassess COWS
›
Step 4
Repeat 4 mg q2h PRN
Max 12 mg Day 1
Maintenance Target
8 – 16 mg as a single daily dose.
Suppresses craving and withdrawal; holds patient in treatment.
Pregnancy Pharmacokinetics
Latter half of pregnancy may require split dosing (TID–QID) due to altered pharmacokinetics.
Doses >16 mg increase diversion risk. FDA approves up to 24 mg/day. Use above 16 mg only in rare, documented cases.
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07 — Buprenorphine/Naloxone in Pregnancy

Formulation Naloxone Component Preferred Use
Buprenorphine/Naloxone
Suboxone		 Minimally absorbed sublingually; no clinically significant fetal effect Preferred — reduces diversion risk; avoids postpartum medication change
Buprenorphine monotherapy
Subutex		 None Higher diversion potential; previously standard but now less preferred
A growing body of evidence supports the combination product for all patients, including pregnant women. Naloxone taken sublingually as directed has virtually no systemic effect.
Counsel all patients that Neonatal Opioid Withdrawal Syndrome (NOWS) is treatable and can occur with either formulation.
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08 — Lactation Compatibility

Buprenorphine and buprenorphine/naloxone are compatible with lactation. Stable patients not using other substances should be encouraged to breastfeed.
Breastmilk Levels
Low transfer of buprenorphine and metabolites into breastmilk.
Infant Exposure
Buprenorphine is poorly bioavailable orally → minimal infant exposure.
Naloxone
Not orally bioavailable; unlikely to affect breastfeeding infant.
Breastfeeding may also reduce severity of NOWS in the newborn.
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09 — Psychosocial Treatment & Monitoring

Psychosocial Components
Group therapy (especially with pregnant/postpartum peers) • Motivational Interviewing • OUD education • Community support/mutual help groups • Individual counseling as needed • Psychiatric co-morbidity screening and treatment
Monitoring Protocol
Weekly office visits (early treatment) • At-visit and unannounced urine toxicology • Pill/film counts • PDMP checks • Observed ingestion at initiation • Frequency guided by patient stability
Psychosocial treatment is a mandatory adjunct to pharmacotherapy — not optional.
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10 — Responding to Patient Behaviors

Relapse or continued use is NOT an automatic indication to discontinue buprenorphine. It should prompt re-evaluation of the treatment plan and intensification of support.
Diversion / Misuse Red FlagClinical Response
Claims of naloxone intolerance (to obtain mono-product)Investigate; document; do not substitute without evidence
Early refill requests; lost/stolen medicationIncrease monitoring; consider observed dosing
Positive illicit tox or negative buprenorphine toxDiscuss; adjust dose or increase visit frequency
Sudden dose increase request (previously stable)Re-evaluate clinical status; assess for relapse
Missed appointments; poor psychosocial engagementOutreach; consider more structured program
A well-managed relapse can strengthen the patient–provider alliance. Individualize all treatment plan changes.
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11 — Pain Management in Buprenorphine-Maintained Patients

Preferred Approaches
Non-narcotics first: acetaminophen, NSAIDs.

Temporarily increase and/or split buprenorphine dose for mild-moderate acute pain.

Regional anesthesia or IV fentanyl for labor/delivery.

Short-acting full opioid agonists for post-op pain (higher doses may be required).
Contraindicated
Nalbuphine (Nubain) and Butorphanol (Stadol) are opioid agonist-antagonists.

These agents will precipitate acute withdrawal in patients chronically using opioids.

Do not administer under any circumstances.
Continue buprenorphine through delivery and postpartum to prevent the need for re-induction. Prescribe naloxone to all patients and household members.
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Key Clinical & Counseling Takeaways

Diagnose Carefully
DSM-5 criteria + urine drug testing. Assess psychiatric co-morbidities and social determinants.
Induct Safely
Wait for COWS ≥ 12. Start 4 mg SL. Prefer in-office induction in pregnancy. Max 12 mg Day 1.
Maintain Comprehensively
8–16 mg daily. Combination product preferred. Breastfeeding encouraged. Psychosocial treatment is mandatory.
Monitor with Compassion
Use urine tox, PDMP review, pill counts, and close follow-up. Relapse should trigger reassessment and stronger support, not abandonment.
Avoid Harm
Never use nalbuphine or butorphanol. Continue buprenorphine through delivery. Prescribe naloxone to all.
What Patients Need to Hear
Treatment protects both parent and baby, NOWS is expected and treatable, and breastfeeding is often possible when recovery is stable.
Source: Dartmouth-Hitchcock CARPP Guidelines  |  DoctorsWhoCode.blog  |  OpenMFM.org
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