Opioids During Pregnancy: Risks, Withdrawal, and Monitoring

When a pregnant person uses opioids-whether prescribed for pain or used as part of an opioid use disorder-the effects don’t stop with them. The baby is exposed too. And that exposure can lead to serious, measurable consequences after birth. The good news? We now know how to manage this safely. The better news? Treatment works. Medication-assisted treatment (MAT) with buprenorphine or methadone isn’t just safer than quitting cold turkey-it’s the standard of care, backed by decades of clinical data and major medical organizations like the American College of Obstetricians and Gynecologists (ACOG) and the CDC.

Why Medication Is Safer Than Quitting

Many people assume that stopping opioids during pregnancy is the best move. It’s not. Medically supervised withdrawal increases the risk of miscarriage, preterm labor, and fetal distress. Studies show relapse rates during withdrawal are 30-40% higher than when staying on medication. That’s not just a number-it means more babies born too early, more mothers returning to unsafe use, and more hospitalizations for everyone involved.

When someone stays on a stable dose of methadone or buprenorphine, their body isn’t going through the rollercoaster of highs and crashes. That stability helps the placenta deliver oxygen and nutrients more consistently. Babies born to mothers on MAT weigh, on average, 200-300 grams more than those born to mothers who withdrew. They’re also born later-often 1-2 weeks closer to full term-and have better head circumference measurements. These aren’t small differences. They mean fewer NICU stays, fewer breathing problems, and a real shot at coming home with their mom.

Neonatal Opioid Withdrawal Syndrome (NOWS)

Almost every baby exposed to opioids in the womb will show signs of withdrawal after birth. That’s not a failure of treatment-it’s expected. This condition, now called Neonatal Opioid Withdrawal Syndrome (NOWS), affects 50-80% of exposed infants. Symptoms usually show up between 48 and 72 hours after birth. You’ll see high-pitched crying, jittery movements, fever over 37.2°C, breathing faster than 60 breaths per minute, and more than three loose stools an hour. Some babies struggle to eat or sleep. Others are so irritable they can’t be comforted.

Hospitals use scoring tools like the Finnegan scale to measure severity. A score of 8 or higher on the Clinical Opioid Withdrawal Scale (COWS) usually means the baby needs medication. But here’s the shift in care: newer protocols like the Eat, Sleep, Console model are changing outcomes. Instead of jumping straight to morphine or methadone, teams first try non-drug support-skin-to-skin contact, quiet rooms, swaddling, feeding on demand. Hospitals using this approach report 30-40% fewer babies needing medication. That’s huge. It means less exposure to drugs for newborns and shorter hospital stays.

Buprenorphine vs Methadone: What’s the Difference?

There are two main medications used in pregnancy: methadone and buprenorphine. Both are effective, but they have different profiles.

Methadone has been the gold standard for decades. It’s taken daily as a liquid, starting around 10-20 mg and often going up to 60-120 mg. It keeps mothers stable-70-80% stay in treatment after six months. But babies born to mothers on methadone tend to have more severe withdrawal. On average, they stay in the hospital 17.6 days and need higher doses of medication to manage symptoms.

Buprenorphine, taken as a sublingual tablet or film, usually starts at 2-4 mg and can go up to 24 mg daily. It’s easier to access because it doesn’t require daily clinic visits like methadone. About 60-70% of mothers stay in treatment with it. Babies exposed to buprenorphine have less severe withdrawal than those exposed to methadone, but still need treatment in about 46% of cases. Their hospital stays average 12.3 days.

Then there’s naltrexone-a different kind of medication. It blocks opioids instead of replacing them. In a 2022 study, infants exposed to naltrexone during pregnancy had a 0% rate of NOWS. That’s not a typo. Zero. These babies went home in two days, and 83% of their mothers were able to breastfeed without issues. But here’s the catch: these mothers started treatment later-on average at 28.4 weeks-compared to 19.7 weeks for those on buprenorphine. That delay means they may have been using opioids longer before getting help. So while naltrexone looks promising, timing and access are still major barriers.

What About Breastfeeding?

Yes, you can breastfeed while on methadone or buprenorphine. The amount of medication that passes into breast milk is tiny-far less than what the baby was exposed to in the womb. In fact, breastfeeding can actually reduce the severity of withdrawal symptoms. Babies who breastfeed tend to need less medication and leave the hospital sooner.

That’s not always easy. Many mothers feel judged. One mother on a recovery forum wrote, “The nurse told me to pump and dump because ‘it’s not safe.’ I cried for an hour.” That stigma is real. But guidelines from the American Academy of Pediatrics and CDC clearly say breastfeeding is encouraged unless the mother is using illicit drugs, has HIV, or is on high-dose opioids without medical supervision.

Naltrexone is different. Since it blocks opioids entirely, it’s not recommended during breastfeeding because it could interfere with the baby’s natural pain response. But for mothers on methadone or buprenorphine, breastfeeding is a powerful tool-not a risk.

Monitoring and Care Coordination

Managing opioid use in pregnancy isn’t just about medication. It’s about care teams. You need an OB-GYN, an addiction specialist, a pediatrician, a social worker, and often a mental health provider-all talking to each other. Too often, that doesn’t happen. As of 2021, only 45% of U.S. hospitals had standardized protocols for this. In rural areas, it’s worse-only 28% offer on-site MAT.

Monitoring starts early. Ideally, treatment begins at the first prenatal visit-between 8 and 12 weeks. That’s when you can catch problems before they spiral. Babies need to be watched for at least 72 hours after birth. Nurses check every 3-4 hours during the first day, then every 4-6 hours after that. The goal isn’t to eliminate all symptoms-it’s to keep the baby comfortable and growing.

And it’s not just physical. About 30% of pregnant women with opioid use disorder screen positive for moderate to severe depression. Over 40% report postpartum depression. Treatment must include mental health support. Trauma-informed care isn’t a buzzword here-it’s a necessity.

What’s New in 2025?

The field is evolving. In 2023, the FDA approved Brixadi, a once-weekly extended-release form of buprenorphine. Early data shows 89% of pregnant women stayed in treatment at 24 weeks-better than daily pills. The NIH’s HEALing Communities Study, running through 2025, is testing full-integration models: MAT + mental health + housing help + peer support. Early results show a 22% drop in NOWS severity when all these pieces come together.

One big problem? Access. Even though the 2020 SUPPORT Act requires Medicaid to cover MAT for pregnant women, only 32 states fully comply. Many clinics still require prior authorization. Some won’t take Medicaid at all. That’s not just a policy gap-it’s a life-or-death barrier.

Real Stories, Real Outcomes

One mother on a recovery forum shared: “My baby scored 12 on the Finnegan scale. They put him on morphine. We were in the hospital for 14 days. I felt like I failed.” Another said: “I got on buprenorphine at 14 weeks. My baby cried for two days, then slept through the night. We went home at 72 hours.” And another: “Naltrexone let me deliver a baby with zero withdrawal. We left after two days. I didn’t have to choose between being clean and being a mom.”

These aren’t outliers. They’re outcomes. And they show that recovery is possible-with the right support.

What You Need to Know

If you’re pregnant and using opioids, you are not alone. And you are not failing. Treatment exists. It works. The goal isn’t perfection-it’s stability. The goal is to keep you safe, your baby safe, and your family together.

Start with your OB-GYN. Ask about MAT. Ask about local programs. Ask about mental health support. Don’t wait until you’re in crisis. The earlier you start, the better the outcome-for you and your baby.