Opioids During Pregnancy: Risks, Withdrawal, and Monitoring

When a pregnant person is using opioids-whether prescribed for pain or as part of an opioid use disorder-the stakes aren’t just personal. They’re medical, emotional, and deeply tied to the health of a growing baby. The idea of stopping opioids cold turkey during pregnancy might seem like the safest choice, but the reality is far more complex. Stopping abruptly can trigger serious complications: preterm labor, fetal distress, even miscarriage. The better path? Medication-assisted treatment (MAT), which stabilizes the mother and gives the baby the best chance at a healthy start.

Why Stopping Opioids Isn’t the Answer

Many assume that if opioids are harmful, then quitting them entirely during pregnancy is the solution. But research shows that medically supervised withdrawal doesn’t work well in this context. Between 30% and 40% of people who try to stop opioids during pregnancy relapse within weeks. And when that happens, the risks spike. Preterm labor becomes 25-30% more likely. Fetal distress rises. The chance of losing the pregnancy increases too.

The American College of Obstetricians and Gynecologists (ACOG), the CDC, and addiction specialists all agree: staying on a stable, controlled medication is safer than quitting. It’s not about replacing one drug with another-it’s about preventing the physical chaos of withdrawal, which affects both mother and baby.

What Is Medication-Assisted Treatment (MAT)?

MAT uses FDA-approved medications to help manage opioid use disorder during pregnancy. The two main options are methadone and buprenorphine. Both work by binding to the same brain receptors as opioids, but without causing the highs or crashes. This keeps cravings and withdrawal symptoms under control.

Methadone is taken daily in a clinic setting. Doses usually start at 10-20 mg and are slowly increased to 60-120 mg daily, depending on the individual’s needs. Buprenorphine, often sold under the brand name Suboxone, is taken as a dissolving tablet under the tongue. It usually starts at 2-4 mg and can be increased to 8-24 mg daily. Both are safe during pregnancy and have been studied extensively.

A key benefit? MAT reduces relapse by 60-70% compared to trying to quit without medication. Babies born to people on MAT tend to weigh more-on average 200-300 grams heavier-and are born later, often 1-2 weeks closer to full term. Their heads are also larger, which is a sign of better brain development.

Neonatal Abstinence Syndrome (NAS) - What It Is and What It Isn’t

If you’ve heard of NAS-now often called Neonatal Opioid Withdrawal Syndrome (NOWS)-you might think it’s a sign that treatment failed. It’s not. It’s a normal, expected, and treatable response to the baby being born into a world without the opioids they were exposed to in the womb.

Between 50% and 80% of babies exposed to opioids in utero will show signs of withdrawal. Symptoms usually appear 48-72 hours after birth. They can include:

• High-pitched crying
• Tremors or jitteriness
• Feeding problems-difficulty sucking or swallowing
• Fast breathing (over 60 breaths per minute)
• Temperature changes (above 37.2°C)
• Loose stools (more than 3 per hour)

These symptoms aren’t a death sentence. They’re a signal that the baby’s nervous system is adjusting. Most babies respond well to non-drug care: skin-to-skin contact, quiet rooms, swaddling, and frequent feeding.

Comparing Methadone, Buprenorphine, and Naltrexone

Not all MAT options are the same. Here’s how they stack up:

Naltrexone is different. It doesn’t activate opioid receptors-it blocks them. This means it’s not used to treat active opioid dependence. It’s only safe if the person has been opioid-free for at least 7-10 days. In one 2022 study, babies exposed to naltrexone showed zero signs of withdrawal. Their mothers had shorter hospital stays and higher breastfeeding rates. But here’s the catch: many of these mothers didn’t get prenatal care until 28 weeks, while those on buprenorphine started at 19 weeks. That delay raises red flags. Naltrexone isn’t a first-line treatment for pregnant women with active opioid use disorder.

Methadone keeps more mothers in treatment long-term, but it tends to cause more severe withdrawal in babies. Buprenorphine often leads to shorter hospital stays and slightly better breastfeeding outcomes. The choice isn’t about which is “better”-it’s about what fits the person’s life, access to care, and medical history.

How Babies Are Monitored After Birth

Every hospital should have a plan to watch for withdrawal symptoms. The CDC recommends monitoring for at least 72 hours after birth. In the first 24 hours, checks happen every 3-4 hours. After that, every 4-6 hours.

The traditional tool for this is the Finnegan scale, which scores symptoms like crying, sleep, and muscle tone. But many hospitals are switching to the Eat, Sleep, Console model. It asks three simple questions:

1. Can the baby eat well?
2. Can the baby sleep for at least an hour at a time?
3. Can the baby be comforted without medication?

Hospitals using this approach report 30-40% fewer babies needing medication for withdrawal. It’s less about numbers on a chart and more about whether the baby is thriving.

What About Breastfeeding?

Breastfeeding is not only safe for most babies exposed to opioids in utero-it’s encouraged. The small amount of medication that passes into breast milk is usually not enough to cause harm. In fact, breastfeeding can reduce the severity of withdrawal symptoms.

Mothers on methadone or buprenorphine can breastfeed. Those on naltrexone, if they’ve been cleared for it, have even higher success rates. The key is avoiding additional substances-alcohol, cigarettes, or recreational drugs-which can make breastfeeding unsafe.

The Real Barriers: Access, Stigma, and Mental Health

Even with all the science on our side, many pregnant people still face huge obstacles. Only 45% of U.S. hospitals have standardized protocols for treating opioid use disorder in pregnancy. In rural areas, that number drops to 28%. Many don’t have on-site MAT services. Others don’t know how to refer patients.

Stigma is just as powerful. One mother on a recovery forum wrote: “The nurse rolled her eyes when I asked about buprenorphine. Like I was asking for a drug, not care.” That kind of attitude pushes people away from help.

And mental health? It’s often ignored. Over 30% of pregnant women in substance use treatment screen positive for moderate to severe depression. Nearly 42% report postpartum depression. Treatment must include therapy, support groups, and trauma-informed care-not just pills.

New Developments and What’s Coming

In 2023, the FDA approved Brixadi, a long-acting buprenorphine injection given once a week or once a month. Early trials show 89% of pregnant women stayed in treatment for 24 weeks, compared to 76% with daily pills. That’s a big win for people who struggle with daily routines or clinic visits.

The American Academy of Pediatrics now says: try non-drug care for at least two hours before reaching for medication. That means more cuddling, more skin-to-skin time, more quiet. It’s simple, but powerful.

The NIH’s HEALing Communities Study is testing full-team care-adding housing support, transportation help, mental health counseling-to see if it reduces NAS severity. Early results show a 22% drop in symptoms when all these pieces come together.

What You Need to Know

If you’re pregnant and using opioids, you’re not alone. And you’re not failing. The goal isn’t perfection-it’s safety. MAT saves lives. It gives you stability. It gives your baby a better start.

Start treatment as early as possible. Ideally, by 8-12 weeks. Talk to your OB-GYN or midwife. Ask for a referral to an addiction specialist. Don’t wait until you’re in crisis.

You don’t have to choose between being a good mom and being healthy. With the right care, you can be both.