Recommendations for opioid agonist pharmacotherapy and against medically assisted withdrawal were based upon early reports that associated withdrawal with maternal relapse and fetal demise. Data from recent case series have called these recommendations into question. Although these data do not support an association between medically assisted withdrawal and fetal demise, relapse remains a significant clinical concern with reported rates ranging from 17% to 96% (average 48%). Given the high loss to follow-up in these studies, the actual relapse rate is likely even greater. Furthermore, while medically assisted withdrawal is being proposed as a public health strategy to reduce neonatal abstinence syndrome (NAS), current data do not support a reduction in NAS with medically assisted withdrawal relative to opioid agonist pharmacotherapy. Overall, the data do not support either benefit of medically assisted withdrawal or equivalence to opioid agonist pharmacotherapy for the maternal-newborn dyad. Medically assisted withdrawal increases the risk of maternal relapse and poor treatment engagement and does not improve newborn health. Treatment of chronic maternal disease, including opioid agonist disorder, should be directed toward optimal long-term outcome.