Table 1: Considerations in Choosing Methadone or Buprenorphine for OUD Treatment During Pregnancy [a]
Factor Buprenorphine Methadone
SettingAvailable through office-based prescription or a specialty OTP
  • Available only through a specialty OTP
  • Pregnant individuals receive priority access
Initiation requirement
  • Mild opioid withdrawal required before treatment can be initiated [b]
  • Cautious, slow, and low-dose induction advised [c]
Withdrawal not required
Safety and effectiveness
  • Safe throughout pregnancy, labor, delivery, and postpartum
  • Dose can be increased to control cravings and prevent withdrawal
  • Dose increase may be required later in pregnancy to maintain the appropriate effect
Treatment durationContinue treatment throughout pregnancy, labor, delivery, and postpartum
Can the regimen be changed?Switch to methadone is possible if needed to control cravings and avoid opioid withdrawalSwitch to BUP is not advised because of the potential for precipitated opioid withdrawal symptoms
Effect on opioid useEqually effective in reducing opioid use during pregnancy [Minozzi, et al. 2020]
Effect on infant
  • Duration, severity, and dose of medication required for NOWS may be reduced
  • No known effects on growth or cognitive or psychological development
No known effects on growth or cognitive or psychological development
Pain managementNonopioid and opioid analgesic agents are used in addition to the maintenance OUD treatment dose of methadone or BUP [ASAM(b) 2020]. The addition of a short-acting full-agonist opioid can be considered for managing moderate to severe acute pain. When adding a full-agonist opioid analgesic, patients will likely need a higher dose than opioid-naive patients to achieve adequate analgesia.
BreastfeedingBreastfeeding, breastmilk, and skin-to-skin contact all reduce the severity and duration of NOWS

Abbreviations: BUP, buprenorphine; NOWS, neonatal opioid withdrawal syndrome; OTP, opioid treatment program; OUD, opioid use disorder.

Notes:

a
b
c

Slow, low-dose induction: Initiate treatment with 2 mg of BUP, followed 30 to 60 minutes later by an additional 2 mg. The pattern of increasing BUP in 2 mg increments and waiting 30 to 60 minutes before the next increase continues until the dose is sufficient to control opioid cravings and prevent withdrawal.

From: Substance Use Disorder Treatment in Pregnant Adults

Cover of Substance Use Disorder Treatment in Pregnant Adults
Substance Use Disorder Treatment in Pregnant Adults [Internet].
Ramsey KS, Stancliff S, Stevens LC, et al.
Baltimore (MD): Johns Hopkins University; 2021 Jul.
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