MedicationPrenatal careSupport
You
& your baby
& your baby
Opioid dependence & pregnancy
Stopping opioids in pregnancy is usually the more dangerous choice
A patient guide to medication treatment, newborn withdrawal, and the care that continues after birth.
Sources [4], [11], [13], [16] • Slide 1 / 22
Your care journey
You can make a plan for every stage
Three things to understand before you leave today.
- 1
Pregnancy
Stay on treatment, or start it, and adjust the dose as you grow.
- 2
Birth
Plan pain relief and know how your baby will be monitored.
- 3
After birth
Keep treatment, feeding, and support in place through the fourth trimester.
Sources [11], [22], [24] • Slide 2 / 22
Your instinct, and the safer plan
Wanting to protect your baby is right. Stopping suddenly is not the way.
Almost every patient asks the same question early in pregnancy: should I just stop?
“If I stop taking opioids, my baby will not go through withdrawal.”
WHAT WE HEAR
The instinct is protective
You are trying to shield your baby from withdrawal. That instinct is correct, and nobody should talk you out of caring about your baby's exposure.
WHAT THE EVIDENCE SHOWS
The method is what changes
In pregnancy, medically supervised withdrawal is discouraged. Treatment with methadone or buprenorphine is the recommended approach instead.
Your goal and your team's goal are identical. What differs is how to reach it safely, and that is what the rest of this guide is about.
Withdrawal also called detoxification, or a taper, is the process of stopping opioids under medical supervision.
Sources [8], [11], [13], [22] • Slide 3 / 22
Two roads
Steady treatment, not withdrawal, is the recommended path
Both options sound reasonable until you look at what happens to the fetus in each.
Stopping all opioids abruptly
- Withdrawal begins, and hormones that drive withdrawal cross the placenta.
- The fetus goes through the same withdrawal, with a racing heart and reduced oxygen delivery.
- Tolerance falls within days, so your pre-treatment dose can become a fatal overdose if you use again.
- Cycles of using and withdrawing repeat through the pregnancy.
Relapse after medically supervised withdrawal is the common outcome, not the rare one.
Staying on steady treatment
- One medicine at a stable level keeps withdrawal and cravings controlled.
- The fetus experiences steady exposure rather than repeated swings.
- Prenatal visits, monitoring, and treatment continue without interruption.
- The newborn team knows what to expect and can plan for newborn withdrawal in advance.
Steady beats stopped: for you, for the pregnancy, and for your baby.
A stable level of medicine is easier on a fetus than repeated withdrawal. That is the single most important clinical point in this presentation.
Sources [4], [6], [11], [13], [16] • Slide 4 / 22
Why steady matters
Withdrawal reaches the fetus, and it does not happen just once
Withdrawal is not only a maternal experience. The same hormonal surge affects the pregnancy.
Stopping: repeated swings
Cycles of opioid effect, withdrawal, and return to use — each surge reaches the fetus.
Stopping: each peak is intoxication, each trough is withdrawal — the fetus follows both.
Treatment: one steady level, and withdrawal is managed after birth under monitoring.
This diagram is a teaching schematic, not data from a study.
Sources [6], [8], [11], [13], [16] • Slide 5 / 22
If you have already stopped
Relapse after withdrawal is common, and the overdose danger is real
This is the part patients most often do not hear before trying to stop.
THE NUMBER
Relapse is the rule, not the exception
Reported relapse rates after medically supervised withdrawal in pregnancy exceed 70% to 90%. Withdrawal is not a treatment for opioid use disorder; it is an interruption of it.
THE DANGER
Tolerance falls fast
Even a few days without opioids lowers your tolerance. Returning to your previous amount can cause a fatal overdose, and this risk persists after birth.
THE FETUS
Withdrawal is not benign for the pregnancy
Reported risks include fetal distress, meconium passage, preterm birth, placental abruption, and in the worst cases fetal death.
If you have already stopped and are struggling, that is a medical situation to bring to your team right away, not a failure to hide.
Sources [4], [6], [13], [16] • Slide 6 / 22
Newborn withdrawal syndrome
Newborn withdrawal is treatable, not a reason to stop treatment
This is the single most common reason patients ask to come off medication. It is worth slowing down here.
WHAT IT IS
Predictable
Signs of newborn opioid withdrawal syndrome (NOWS, also called neonatal abstinence syndrome, or NAS) follow a known timeline. Your baby's team expects it and watches for it.
HOW IT IS TREATED
Usually without medicine
Rooming-in with you, skin-to-skin contact, quiet low light, frequent feeding, and swaddling. The Eat, Sleep, Console approach starts here and reduces how often medicine is needed.
WHY IT MATTERS
Not comparable to overdose
Withdrawal in a monitored newborn is managed and reversible. Overdose in a parent can be fatal, and an unstable home is a lasting harm.
Wanting to protect your baby is correct. Stopping treatment is the version of that instinct most likely to hurt you both.
Some babies do need temporary medicine for withdrawal. Needing it is not a sign you did something wrong, and it does not mean the treatment failed.
Sources [8], [9], [14], [24] • Slide 7 / 22
Choosing your medicine
Methadone and buprenorphine are both first-line choices in pregnancy
Naltrexone is a third option, but it works differently and is rarely started during pregnancy.
METHADONE
Full agonist
Fully replaces the opioid effect. Started without needing you to be in withdrawal. Dispensed through a licensed opioid treatment program (OTP) with daily dosing.
BUPRENORPHINE
Partial agonist
Partially replaces the opioid effect and blocks it at the receptor. Prescribed from an office or clinic. You must be in mild to moderate withdrawal before the first dose.
NALTREXONE
Antagonist
Blocks opioids entirely. Starting it requires 7 to 14 opioid-free days, which is why it is generally not started during pregnancy.
Neither methadone nor buprenorphine is "the best" for everyone. The right one is the one you can stay on steadily for the rest of your pregnancy.
What stops treatment from working is stopping treatment, not the specific drug you chose.
Sources [11], [12], [14], [16], [22] • Slide 8 / 22
Head to head
Buprenorphine favors the newborn; methadone favors staying in treatment
Most of this evidence comes from large observational studies, so read it as average patterns rather than a promise about your baby.
| Outcome | Methadone | Buprenorphine |
|---|---|---|
| Staying in treatment | Better long-term retention. In a nationwide cohort, fewer patients stopped methadone than buprenorphine during pregnancy and the postpartum year. | Higher rate of stopping, especially early, during induction and the first weeks. |
| Newborn withdrawal | Higher rates of withdrawal serious enough to need medicine. | Lower risk and lower severity; less morphine needed for treatment and a shorter newborn hospital stay. |
| Birth weight | Lower average birth weight and smaller head circumference on average. | Higher average birth weight. |
| Weeks of pregnancy at birth | Slightly earlier average delivery. | Lower risk of preterm birth. |
| Cesarean birth | About 33.1% in one large cohort. | About 33.6% — essentially the same. |
| Severe maternal complications | About 3.5% in the same cohort. | About 3.3% — essentially the same. |
Cesarean and severe-complication figures come from the same cohort, so the two medicines are compared like for like. Differences in newborn outcomes are the most consistent finding; retention differences favor methadone.
Percentages and adjusted comparisons are drawn from a single large pregnancy cohort and should not be read as your individual risk.
Sources [12], [15], [16], [18], [19], [21] • Slide 9 / 22
In plain numbers
The maternal differences are small; the newborn differences are the real ones
Both medicines are safe for you. Where they differ most is in what your baby goes through after birth.
33.1%
Methadone
33.6%
Buprenorphine
3.5%
Methadone
3.3%
Buprenorphine
More
Methadone: stayed in treatment
Fewer
Buprenorphine: stayed in treatment
Cesarean birth and severe maternal complications: methadone 33.1% and 3.5%, buprenorphine 33.6% and 3.3% in the same large pregnancy cohort — a difference too small to choose on. Retention favors methadone. The third chart shows direction only, not a measured percentage.
Do not pick a medicine on the maternal complication numbers. Pick it on newborn outcomes, your tolerance, and which one you can stay on.
Sources [18], [19], [23] • Slide 10 / 22
For your baby
On average, buprenorphine means less withdrawal treatment for your newborn
This is the most consistent difference between the two medicines, and it is the one patients care about most.
Lower
Buprenorphine: preterm birth
Higher
Methadone: preterm birth
Higher
Buprenorphine: birth weight
Lower
Methadone: birth weight
Less often
Buprenorphine: medicine needed
More often
Methadone: medicine needed
Direction of effect as reported in systematic reviews and a large cohort: buprenorphine is linked with lower preterm birth, higher average birth weight, and milder newborn withdrawal needing less morphine and a shorter hospital stay. Charts show direction only — they are not measured percentages.
If your main goal is the gentlest possible start for your baby, buprenorphine is usually the stronger choice. If staying in treatment is your main risk, methadone may protect you better.
These are average findings across groups of patients, mostly from observational studies. They predict what tends to happen, not what will happen to your baby.
Sources [12], [14], [15], [16], [18], [21] • Slide 11 / 22
Methadone
Methadone starts without withdrawal and is dispensed daily at a program
It is often the better fit when opioid tolerance is high, when buprenorphine caused precipitated withdrawal before, or when structure helps you stay well.
STARTING
No withdrawal needed
Methadone is started at a low dose, usually 10 to 30 mg daily, and raised gradually until you feel steady. You do not have to be in withdrawal first.
HOW IT IS GIVEN
Licensed program
A federally certified opioid treatment program dispenses the medicine, usually daily and observed, with counseling and monitoring built in.
WHAT IT IS GOOD AT
Staying steady
Of the two first-line medicines, methadone keeps more people in continuous treatment through pregnancy and the postpartum year.
The daily visit is a benefit for some patients and a burden for others. Say which one it is for you, because that answer changes which medicine fits.
Sources [6], [11], [12], [14], [19], [20], [22] • Slide 12 / 22
Adjusting the dose
Your dose often needs to go up as pregnancy advances
Plateauing or feeling worse as the months pass is expected biology, not a sign of failure.
WHY
Your body clears the medicine faster
Blood volume rises and liver enzyme activity increases in the second and third trimesters, so methadone is cleared faster and its effect wears off sooner.
WHAT HELPS
A higher or split dose
Many patients need a dose increase, or the daily dose divided into two doses, to prevent withdrawal symptoms later in the day.
A higher dose does not make newborn withdrawal worse. A dose that is too low leaves you and your baby cycling through withdrawal.
Tell your team about symptoms that come on before your next dose: yawning, sweating, restlessness, stomach cramps, runny nose, or a change in your baby's movement.
Dose adjustment decisions are individualized by your treatment program and obstetric team.
Sources [5], [6], [9], [11] • Slide 13 / 22
Buprenorphine
Buprenorphine can be prescribed from a clinic, but timing the first dose matters
The main practical catch is induction: too early and it can cause sudden, intense withdrawal.
WHERE
Office or clinic
Prescribed by a clinician rather than dispensed daily at a program, which makes it easier to combine with work, childcare, and prenatal visits.
BEFORE THE FIRST DOSE
You must be in withdrawal
Buprenorphine is started once you have mild to moderate withdrawal, typically a COWS score of about 8 to 12. Starting too early causes precipitated withdrawal.
WHAT IT IS GOOD AT
The newborn
Lower risk and severity of newborn withdrawal, less medicine needed for the baby, shorter newborn hospital stay, and higher average birth weight.
If you have been on methadone and want to switch, or the reverse, make that plan with your team. Do not switch on your own.
Precipitated withdrawal is abrupt and severe. It is the one buprenorphine problem that good timing prevents.
Sources [10], [11], [12], [14], [15], [16], [18], [20] • Slide 14 / 22
Which form of buprenorphine
Buprenorphine with naloxone is now considered acceptable in pregnancy
Older practice preferred the single-ingredient form. The evidence no longer supports that restriction.
THE OLD CONCERN
Theory, not findings
Combination buprenorphine-naloxone was avoided because of a theoretical worry that the naloxone part could harm the fetus. Naloxone taken by mouth has very low absorption, and that worry has not held up.
CURRENT EVIDENCE
Equivalent safety
Reviews of buprenorphine-naloxone used through pregnancy, at doses of about 8 to 20 mg, show no increase in birth defects, no worse perinatal outcomes, and no difference in newborn withdrawal.
Either form is clinically acceptable. Take the form you can actually get and stay on, and ask your clinician to confirm the plan for the first dose.
Do not let the choice between two equivalent forms delay starting treatment.
Sources [2], [5], [8], [10], [17] • Slide 15 / 22
Naltrexone
Naltrexone is usually not started in pregnancy, but it is often reasonable to continue
Starting and continuing are two different questions, and they get two different answers.
STARTING DURING PREGNANCY
Generally not advised
Naltrexone cannot be started while opioids are in your system. It requires 7 to 14 opioid-free days confirmed by a negative drug screen, and that window carries a real risk of relapse and fetal stress.
CONTINUING AN EXISTING PLAN
Often reasonable
If you conceived while stable on oral or long-acting injectable naltrexone, continuing is reasonable after weighing the limited long-term developmental data against the immediate risk of relapse if you stop.
Never stop naltrexone because you found out you are pregnant. That is a decision to make with your clinician, not before speaking to one.
Naltrexone appears to carry a much lower risk of newborn withdrawal than either agonist, but the number of pregnancies studied is small. That is a real limitation, not a detail.
Naltrexone's fetal and neonatal evidence base is small; comparisons with methadone and buprenorphine rest on limited sample sizes.
Sources [1], [3], [4], [5], [10], [11] • Slide 16 / 22
The part that is rarely explained
Pain relief in labor works differently when you take methadone or buprenorphine
This is one of the most common fears, and one of the most fixable.
WHAT IS TRUE
Your maintenance dose is not pain relief
Methadone and buprenorphine keep withdrawal and cravings away. They do not treat the pain of labor, a surgical incision, or afterpains.
WHAT FOLLOWS
Your maintenance dose continues, and pain is treated on top
You keep taking your usual medicine, and acute pain is treated separately with the full range of options.
An epidural or other neuraxial block
Scheduled acetaminophen
NSAIDs when safe for you
Short-acting opioids titrated to your pain
Indicated pain medicine is never withheld because you have opioid use disorder. If you are told otherwise, ask to speak with your obstetric or anesthesia team.
Sources [11], [22] • Slide 17 / 22
Feeding your baby
Breastfeeding is encouraged on methadone or buprenorphine, at any dose
The amount of medicine that reaches your milk is small, and feeding may soften your baby's withdrawal.
THE BENEFIT
Less severe withdrawal
Only small amounts of methadone and buprenorphine pass into breast milk. Feeding is linked with milder newborn withdrawal and less need for medicine.
THE CONDITIONS
Stable and no non-prescribed use
Breastfeeding is encouraged when you are clinically stable and not using non-prescribed substances or other contraindicated drugs. Your dose is not the deciding factor.
Some situations, such as HIV, change the feeding recommendation. Ask your team for advice specific to you rather than assuming you cannot feed.
If feeding is not possible, expressing milk, donor milk, or formula are all valid ways to care for your baby. Ask for lactation support early.
Sources [7], [8], [11] • Slide 18 / 22
The fourth trimester
The months after birth carry the highest risk of overdose
This is the period when support tends to drop away, and it is exactly when it is needed most.
- Sleep deprivationBroken sleep, recovery from birth, and new demands lower your reserve.
- Changing medicine levelsYour body clears methadone and buprenorphine differently once you are no longer pregnant, so your dose may need review.
- Loss of supportProgram contact, transportation, housing, and childcare often change right after delivery.
- Custody and stressChild welfare involvement and custody decisions add pressure at the same time.
Before you leave the hospital, ask exactly who is following up on your treatment, and when. Write the names and numbers down.
Sources [7], [11], [24] • Slide 19 / 22
Your plan
Five things to remember, and six questions to ask
Remember
- Treatment with methadone or buprenorphine is recommended in pregnancy. Detoxification is not.
- Stopping on your own is the most dangerous option, because tolerance falls and overdose risk rises.
- Buprenorphine tends to be easier on the newborn. Methadone tends to keep more people in treatment.
- Newborn withdrawal is expected, treatable, and usually managed without medicine.
- Ask for pain relief in labor, plan your postpartum follow-up, and keep naloxone with you.
Ask your MFM specialist
- Which medicine do you recommend for me, and why that one?
- Who manages my dose as my pregnancy advances, and how will we know if it is too low?
- What is the plan if I miss doses, or if I use opioids again?
- What pain relief will be available to me during labor and after birth?
- How long will my baby stay in the hospital, and how will withdrawal be treated?
- Who follows up on my treatment after discharge, and how do I reach them?
Bring these questions with you. Asking them is part of good care, not a challenge to your team.
Sources [4], [10], [11], [13], [16], [19], [22] • Slide 20 / 22
Where to get help
Reliable information, real support, and what this guide can and cannot do
CDCTreatment before, during, and after pregnancy
SAMHSA National Helpline1-800-662-4357 — free, confidential, 24/7
KEEP NALOXONE WITH YOU
Overdose is survivable
Ask for a naloxone kit and teach one person you trust how to use it. An overdose response plan is part of postpartum care.
ABOUT THIS GUIDE
Education, not individual advice
This explains how opioid dependence is managed in pregnancy in general terms. Decisions for you belong with your own obstetric, addiction, and newborn teams. No personal health information is included.
Evidence reflects guidance from ACOG, the American Society of Addiction Medicine, and peer-reviewed literature available at publication. Where evidence is limited, particularly for naltrexone in pregnancy, this guide says so. Prepared for OpenMFM.org by Dr. Chukwuma Onyeije, MD, Atlanta Perinatal Associates.
Sources [10], [11], [22], [24] • Slide 21 / 22
References
References
Every clinical statement in this presentation is drawn from the sources below.
- Aravind A, Krishnamoorthy S, Kailasam V, et al. Naltrexone Compared With Buprenorphine or Methadone in Pregnancy: A Systematic Review. Obstet Gynecol. 2024;143(3):432-442.https://pubmed.ncbi.nlm.nih.gov/38227945/
- Buprenorphine-naloxone, buprenorphine, and methadone throughout pregnancy in maternal opioid use disorder. Acta Obstet Gynecol Scand. 2023. PMC9951318.https://pmc.ncbi.nlm.nih.gov/articles/PMC9951318/
- Tran TH, Griffin BL, Stone RH, Vest KM, Todd TJ. Methadone, Buprenorphine, and Naltrexone for the Treatment of Opioid Use Disorder in Pregnant Women. Pharmacotherapy. 2017;37(7):824-839.https://pubmed.ncbi.nlm.nih.gov/28543179/
- Logistic and patient preference-driven therapeutic stance in an opioid-dependent pregnant female: A case report. PMC.https://pmc.ncbi.nlm.nih.gov/articles/PMC7017555/
- Opioid substitution in pregnancy, a narrative review: contemporary evidence for use of methadone and buprenorphine in pregnancy. J Subst Use. 2022. doi:10.1080/14659891.2022.2106600.https://www.tandfonline.com/doi/full/10.1080/14659891.2022.2106600
- Jones HE, Martin PR, Heil SH, et al. Treating Women Who Are Pregnant and Parenting for Opioid Use Disorder and the Concurrent Care of Their Infants and Children: Literature Review to Support National Guidance. J Addict Med. 2017;11(3):178-190.https://pmc.ncbi.nlm.nih.gov/articles/PMC5457836/
- Interventions for opioid use disorder during pregnancy: a scoping review. Front Psychiatry.https://www.frontiersin.org/journals/psychiatry/articles/10.3389/fpsyt.2026.1770262/full
- Opioid use disorder in pregnancy. PMC review. National clinical guidance on opioid use disorder in pregnancy is also available from ACOG at acog.org/womens-health.https://pmc.ncbi.nlm.nih.gov/articles/PMC6830739/
- No. 349-Substance Use in Pregnancy. J Obstet Gynaecol Can. 2017;39(10):922-937.https://pubmed.ncbi.nlm.nih.gov/28935057/
- ACOG. Medications for Addiction Treatment and Pregnancy. Frequently Asked Questions.https://www.acog.org/womens-health/faqs/medications-for-addiction-treatment-and-pregnancy
- ACOG Committee on Obstetric Practice; American Society of Addiction Medicine. Committee Opinion No. 711: Opioid Use and Opioid Use Disorder in Pregnancy. Obstet Gynecol. 2017;130(2):e81-e94.https://www.acog.org/en/Clinical/Clinical%20Guidance/Committee%20Opinion/Articles/2017/08/Opioid%20Use%20and%20Opioid%20Use%20Disorder%20in%20Pregnancy
- 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.https://onlinelibrary.wiley.com/doi/full/10.1111/add.13462
- British Columbia Centre on Substance Use; BC Ministry of Health. Management of opioid use disorders: a national clinical practice guideline. CMAJ. 2018;190(9):E247-E257.https://www.cmaj.ca/content/190/9/E247
- Buprenorphine Compared with Methadone in Pregnancy: A Systematic Review and Meta-Analysis. J Addict Med. 2022.https://pubmed.ncbi.nlm.nih.gov/35758300/
- Suarez EA, Huybrechts KF, Straub L, et al. Buprenorphine versus Methadone for Opioid Use Disorder in Pregnancy. N Engl J Med. 2022;387(22):2033-2044. doi:10.1056/NEJMoa2203318.https://www.nejm.org/doi/10.1056/NEJMoa2203318
- 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. (Neonatal outcomes analysis.)https://pubmed.ncbi.nlm.nih.gov/26864360/
- Safety and Efficacy of Buprenorphine-Naloxone in Pregnancy: A Systematic Review of the Literature. PubMed 36810423.https://pubmed.ncbi.nlm.nih.gov/36810423/
- Buprenorphine: A Better Option for Opioid Use Disorder Treatment in Pregnancy Compared to Methadone. PURLs. J Am Board Fam Med. 2025. PMID 40355279.https://pubmed.ncbi.nlm.nih.gov/40355279/
- Buprenorphine and Methadone Discontinuation During Pregnancy and the Postpartum Period: A Nationwide Cohort Study. Am J Psychiatry. 2025;182(12):1060-1071. doi:10.1176/appi.ajp.20241127.https://pubmed.ncbi.nlm.nih.gov/40859701/
- Methadone versus buprenorphine for the treatment of opioid use disorder in pregnancy: a systematic review and meta-analysis. PubMed 33450195.https://pubmed.ncbi.nlm.nih.gov/33450195/
- Buprenorphine Compared with Methadone in Pregnancy: A Systematic Review and Meta-Analysis. PubMed 35758300.https://pubmed.ncbi.nlm.nih.gov/35758300/
- ACOG. Opioid Use Disorder and Pregnancy. Frequently Asked Questions.https://www.acog.org/womens-health/faqs/opioid-use-disorder-and-pregnancy
- Suarez EA, Huybrechts KF, Straub L, et al. Buprenorphine versus Methadone for Opioid Use Disorder in Pregnancy. N Engl J Med. 2022;387(22):2033-2044. (Retention and maternal outcome analyses.)https://pubmed.ncbi.nlm.nih.gov/36449419/
- Young LW, Ounpraseuth ST, Merhar SL, et al. Eat, Sleep, Console Approach or Usual Care for Neonatal Opioid Withdrawal. N Engl J Med. 2023;388(25):2326-2337. doi:10.1056/NEJMoa2214470. ACOG patient guidance on opioid use disorder in pregnancy is available at acog.org/womens-health/faqs.https://www.nejm.org/doi/10.1056/NEJMoa2214470