Medication for the Treatment of Opioid Use Disorder in Pregnancy Is Essential

Abstract

National practice groups and decades of research strongly support treating opioid use disorder (OUD) as a chronic illness and specifically call for the use of evidence-based medications to treat OUD throughout pregnancy and beyond. The criterionstandard medications for OUD (MOUD), including during pregnancy, are buprenorphine (approved by the US Food and Drug Administration in 2002) and methadone (approved by the US Food and Drug Administration to treat OUD in 1972). 1 While evidence suggests that pregnancy may represent a specific window of opportunity to engage individuals in MOUD and that MOUD leads to better outcomes for the maternal-infant dyad, 2 fewer than 1 in 4 individuals with OUD receive treatment in any given month of pregnancy. 3 Improperly treated OUD (eg, not using MOUD or abruptly stopping opioids during pregnancy) has substantial negative effects, increasing morbidity and mortality for the maternalinfant dyad. Research clearly demonstrates that untreated OUD during pregnancy is associated with a number of detrimental effects on the health of the infant (including structural abnormalities and fetal death) and mother (including overdose and maternal death). 2 Despite overwhelming support for the use of MOUD in pregnancy, 1 there are numerous barriers to engaging people in appropriate care, including stigma among prescribing physicians, inadequate training and resources for clinicians, and patient concerns. The primary concerns expressed by patients related to MOUD in pregnancy include the risk of state intervention (eg, loss of custody, criminal proceedings) and perceived negative implications of medication for the infant, including neonatal abstinence syndrome/neonatal opioid withdrawal syndrome (NAS/NOWS). 4 These issues lead to delayed care or avoidance of appropriate treatment and also contribute to negative outcomes for the maternal-infant dyad. Importantly, there are a number of clinical and legal interventions that have the potential to address these barriers and concerns. These include family-centered, evidence-based approaches to treating NAS/NOWS, like Eat, Sleep, Console, 5 and evolving policies that reduce harms toward historically marginalized populations who have been disproportionately affected by reporting based only on positive drug screens. Mandated state reporting of positive drug screens in pregnant people results in ongoing and harmful family control measures that also affect continuing on MOUD or seeking care. Indeed, many of these institutions (eg, departments of child services or child protective services) encourage people to use nonpharmacological management of their OUD and often place contingencies on patients without consultation with health care teams. Health care professionals working with pregnant and postpartum patients who use opioids must understand the Invited Commentary and Editor's Note