Opioid Use in Pregnancy

First-Line Recommendations for Pregnant Women with Opioid Use Disorder

The American College of Obstetricians and Gynecologists recommends methadone and buprenorphine as the only opioids considered safe for use throughout all trimesters of pregnancy, and they should only be used for opioid use disorder treatment rather than pain management 1, 2, 3
Methadone and buprenorphine are the recommended medications for pregnant women with opioid use disorder (OUD) and should be offered as maintenance therapy throughout pregnancy 4, 5

Methadone has an established safety record in pregnancy with no association with birth defects 1, 2
Buprenorphine has no association with birth defects 1, 2
Neonates exposed to buprenorphine typically have less medication needed to treat neonatal opioid withdrawal syndrome (NOWS), shorter duration of treatment, and shorter hospital stays 5

Opioids used in pregnancy may be associated with risks including stillbirth, poor fetal growth, preterm delivery, and birth defects 6, 7
The Centers for Disease Control and Prevention recommends that codeine should be avoided during breastfeeding due to reports of neonatal toxicity and death 6, 7

The American College of Obstetricians and Gynecologists recommends that for opioid-naïve pregnant women requiring pain management, NSAIDs and acetaminophen should be first-line treatments (unless contraindicated) 4, 8
For labor pain, neuraxial analgesia (epidural) should be encouraged 4, 8

For women with OUD, postpartum pain should be managed with a multimodal approach starting with non-opioid pain relief 4, 8
Women on buprenorphine or methadone for OUD should continue their maintenance therapy during the postpartum period 1, 2

The American College of Obstetricians and Gynecologists recommends that methadone or buprenorphine should not be abruptly discontinued during pregnancy as withdrawal poses risks to both mother and fetus 6, 7

For severe pain not managed by non-opioids, full opioid agonists like fentanyl or hydromorphone may be used for acute severe pain when necessary, as recommended by the American College of Obstetricians and Gynecologists 9
Women already on opioid maintenance therapy should continue their prescribed medications throughout pregnancy, not attempt acute detoxification or weaning during pregnancy, and receive neuraxial labor analgesia (epidural) during delivery, as suggested by the American College of Obstetricians and Gynecologists 9
For women with opioid dependence, postpartum pain should be managed with a multimodal approach starting with non-opioid pain relief, continuation of maintenance therapy (buprenorphine or methadone), and addition of full opioid agonists (e.g., fentanyl or hydromorphone) if needed for acute pain, according to the American College of Obstetricians and Gynecologists 9
Opioid agonist/antagonists like nalbuphine or butorphanol should be avoided as they can precipitate opioid withdrawal, as warned by the American College of Obstetricians and Gynecologists 9
Inhaled nitrous oxide should be avoided in opioid-dependent women due to reduced efficacy and increased sedation risk, as cautioned by the American College of Obstetricians and Gynecologists 9

The initial prescription for short‑acting opioids in pregnant patients with severe pain should be limited to the smallest quantity possible, typically a 7‑day supply, to minimize exposure duration. 10

At each follow‑up visit, clinicians should assess for signs of opioid dependence or misuse (e.g., early refill requests, dose escalation, seeking multiple providers) when opioids are prescribed during pregnancy. 10

The prescription record must document the specific indication, dose, intended duration, and the patient’s response to treatment to ensure safe monitoring and continuity of care. 10