Opioids During Pregnancy: Risks, Withdrawal, and Monitoring

When a pregnant person is using opioids - whether prescribed for pain or used as part of an opioid use disorder - the stakes aren’t just about their own health. The baby’s life, too, hangs in the balance. The good news? We now know how to manage this safely. The bad news? Too many still don’t get the care they need.

Why Opioid Use in Pregnancy Is Different

Opioids cross the placenta. That means whatever the mother takes, the baby gets too. It’s not about willpower or choice. It’s about biology. When a pregnant person stops opioids suddenly - even under medical supervision - the baby goes into withdrawal too. That’s called Neonatal Opioid Withdrawal Syndrome (NOWS), or sometimes Neonatal Abstinence Syndrome (NAS). And it’s not rare. Between 50% and 80% of babies exposed to opioids in the womb will show signs of withdrawal after birth.

The Only Safe Way: Medication-Assisted Treatment

The American College of Obstetricians and Gynecologists, the CDC, and the American Society of Addiction Medicine all agree: medication-assisted treatment (MAT) is the standard of care. That means using methadone or buprenorphine to stabilize the mother’s system - not to get high, but to prevent withdrawal, reduce cravings, and keep her in treatment.

Methadone has been used for decades. Dosing starts low - around 10 to 20 mg a day - and is slowly increased until the person feels stable, usually between 60 and 120 mg daily. Buprenorphine, a newer option, starts at 2 to 4 mg sublingually and can be increased up to 24 mg daily. Both are safe during pregnancy. Neither causes birth defects. Neither increases the risk of miscarriage.

What’s the alternative? Medically supervised withdrawal. It sounds logical. But it doesn’t work. Studies show that 30 to 40% of people who try to quit opioids cold turkey during pregnancy relapse. And relapse means higher risks: preterm labor, fetal distress, even stillbirth. The CDC says withdrawal increases the chance of preterm birth from 15-20% to 25-30%. That’s not a risk worth taking.

What Happens to the Baby?

NOWS symptoms usually show up 48 to 72 hours after birth. The baby might be jittery, cry nonstop, have trouble feeding, sweat, have a high fever (over 37.2°C), or breathe faster than 60 times a minute. They might have loose stools more than three times an hour. These aren’t signs of neglect - they’re signs of physiology.

Hospitals use scoring systems like the Finnegan scale to measure severity. A score of 8 or higher often means medication is needed. But here’s the thing: not all babies need drugs. The Eat, Sleep, Console model - now used in over 650 U.S. hospitals - focuses on keeping the baby calm, feeding often, and holding them close. When this works, it cuts the need for morphine or methadone treatment by 30 to 40%.

Methadone vs. Buprenorphine: What’s Better?

Both work. But they have different trade-offs.

Methadone keeps more mothers in treatment - 70 to 80% stay in care after six months. But babies exposed to methadone tend to have worse withdrawal. Their hospital stays average 17.6 days. Their Finnegan scores are higher, around 14.3 on average.

Buprenorphine? Babies usually have milder symptoms - average Finnegan score of 11.8 - and shorter stays, around 12.3 days. But only 60 to 70% of mothers stay in treatment long-term. And about 46% of these babies still need medication to manage withdrawal.

Then there’s naltrexone. It’s not an opioid. It blocks opioids. In a 2022 Boston Medical Center study, babies exposed to naltrexone had a 0% rate of NOWS. Zero. They went home in two days. Moms were more likely to breastfeed successfully. But here’s the catch: these moms started treatment later - at 28.4 weeks on average - compared to 19.7 weeks for those on buprenorphine. That’s a problem. Starting late means more risk to the baby during the first half of pregnancy.

What About Breastfeeding?

Yes, you can breastfeed while on methadone or buprenorphine. The amount that passes into breast milk is tiny - far less than what the baby was exposed to in the womb. In fact, breastfeeding can actually help reduce withdrawal symptoms. The American Academy of Pediatrics says it’s encouraged unless the mother is HIV-positive or using other unsafe drugs.

One mother on a recovery forum wrote: “I was scared to nurse. But my baby slept better, cried less. We both healed faster.” That’s not anecdotal. It’s backed by data.

Why So Many Are Still Left Behind

Despite all this, 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 clinics don’t have buprenorphine on site. Some don’t even know how to prescribe it.

And stigma? It’s real. One mother shared on Reddit: “The nurse said, ‘You’re lucky you didn’t lose the baby.’ Like I wanted this. Like I chose it.” That kind of judgment makes people hide. It makes them skip appointments. It makes them relapse.

New Hope: Extended-Release Options

In 2023, the FDA approved Brixadi - an extended-release form of buprenorphine given as a weekly or monthly injection. Early data shows 89% of pregnant women stayed in treatment at 24 weeks, compared to 76% with daily pills. That’s huge. Fewer missed doses. Less stress. More stability.

The NIH’s HEALing Communities Study is testing integrated care - combining MAT, mental health support, housing help, and transportation - across 67 sites. Early results? A 22% drop in NAS severity when all pieces are in place.

What You Need to Do

If you’re pregnant and using opioids:

• Don’t stop cold turkey. Talk to a provider who understands addiction medicine.
• Ask about buprenorphine or methadone. These are safe and effective.
• Start treatment as early as possible - ideally by 8 to 12 weeks.
• Find a care team that includes an OB, an addiction specialist, and a pediatrician.
• Ask about the Eat, Sleep, Console approach for your baby after birth.
• Don’t be afraid to breastfeed. It helps.

What’s Next?

The rise in NAS cases - up fivefold from 2010 to 2020 - isn’t just a medical issue. It’s a social one. Nearly half of pregnant women with opioid use disorder are homeless or housing insecure. One in three has depression. One in two has trauma history. Treating the addiction isn’t enough. You have to treat the person.

That means housing. Childcare. Therapy. Transportation. Legal help. Medicaid coverage for MAT is required by federal law since 2020 - but only 32 states fully follow through. That’s unacceptable.

The tools exist. The science is clear. What’s missing is the will to make care accessible, compassionate, and available to everyone - no matter where they live, what they’ve done, or how they got here.