By Sarah Bernstein, MD and Jessica Gray, MD
March 21, 2019
The opioid crisis and rise in overdose deaths in recent years has received a great deal of media attention. Though the media has helped to raise awareness, it has also contributed to stigmatization of individuals struggling with addiction. Pregnant and parenting women are among those who have been severely affected by the epidemic and perhaps most shamed by society for their use. Sadly, at a time when many women feel motivated to connect with the health care system and make healthy choices, women with addiction often avoid interacting with providers due to feelings of shame and mistrust. There are many misconceptions regarding the risks and benefits of medical treatment for women with substance use disorders as well as the treatment of neonatal withdrawal. We hope to dispel some of these myths and provide a better understanding of the evidence supporting the treatment of substance use disorders in the setting of pregnancy as well as neonatal withdrawal.
Myth 1: Medications for opioid use disorder should be stopped in pregnancy to protect the fetus
As obstetric and family medicine physicians who care for women with substance use disorders during their pregnancy, we often meet women asking to discontinue their medications for opioid use disorder (OUD). This request generally stems from women wanting to do everything they can to have healthy babies, misunderstanding the safety and benefits of medications in pregnancy, stigma surrounding opioid use disorder in pregnancy, and fears of child protective services becoming involved at time of delivery.
Pregnancy is a unique and highly motivating time in a woman’s life; many may be entering the health care system formally for the first time in years, and even before a heartbeat can be detected, women express a great attachment to their pregnancy. Though a happy time for many, women with OUD can find this to be a time of great stress. Pregnant and with a history of addiction, women often experience feelings of shame and guilt—they are not sure what to tell their friends and family, they are fearful of exposing their baby to medications, and they worry they will lose custody of their baby. While clinicians may emphasize that addiction is a chronic disease that is prone to flares (relapses) just like diabetes or heart disease, many women believe pregnancy can motivate them to abstain from substances and enter remission. This may be true for some women, but opioid use disorder is a brain-altering disease10 and willpower alone is typically not enough. The American College of Obstetricians and Gynecologists (ACOG) and several other national organizations recommend methadone and buprenorphine (Subutex) as first-line treatment options for opioid use disorder in pregnancy.1 Both have been shown to reduce use of illicit substances in pregnancy and improve outcomes for the fetus, and both reduce rates of overdose and improve rates of long-term remission. Medically-assisted withdrawal (gradual taper off of medication) is not recommended in pregnancy due to high rates of relapse.6 Counseling women about the known safety profile of methadone and buprenorphine in pregnancy14 and the known benefits of staying on an adequate dose of medication is a big part of our job.
Myth 2: Babies are born “addicted”
This concept has gotten a lot of press lately as the opioid epidemic skyrockets and more women have a diagnosis of opioid use disorder at time of delivery. Since the early 2000s, the country has seen the number of babies who are born with neonatal abstinence syndrome (NAS) rise dramatically from about 1 to 2 in 1,000 deliveries up to over 6 in 1,000 deliveries—a five-fold increase.9
The widely-used term NAS is a misnomer as a baby cannot be addicted to a drug (i.e., have cravings or repeated drug use despite negative consequences) just as the baby cannot choose to be “abstinent.” A more medically precise term is starting to get more traction—NOWS, or Neonatal Opioid Withdrawal Syndrome. This more accurately describes the fact that babies born to women who either use illicit opioids or are prescribed opioids during their pregnancy and become dependent on the opioids they are exposed to in utero and will, therefore, go through withdrawal. Why is this difference so important to point out? Because words matter. There is a growing body of literature that demonstrates how impactful the language we chose is on perpetuating stigma and shame for women with opioid use disorder.7,8,2
Myth 3: Treatment of neonatal withdrawal always requires medication and long hospital stays
The treatment of babies with neonatal opioid withdrawal is evolving. Historically, treatment for neonatal opioid withdrawal occurred in the nursery or intensive care unit for close monitoring—essentially, away from the mother. In a paradigm shift, mom is becoming first-line treatment for neonatal opioid withdrawal.13 There is growing evidence that nonpharmacologic treatment for neonatal withdrawal is effective; for some babies, nonpharmacologic treatment is so effective that no medication is needed, and they can go home within four to seven days of birth. Nonpharmacologic treatment includes keeping babies in an environment with low stimulation and providing typical comfort measures such as swaddling, breastfeeding, and holding. In fact, holding a baby can be so effective to manage mild withdrawal symptoms that hospitals now have “cuddler” programs so that babies don’t miss out on this important treatment when parents can’t be at their bedside. When babies are showing signs of more significant withdrawal—difficulty eating, difficulty being consoled despite above measures, or not sleeping4—then they sometimes need medication in addition to nonpharmacologic treatment. Common medications include, but are not limited to, morphine and methadone.
Myth 4: A higher medication dosage will lead to more severe neonatal withdrawal
There are also some misconceptions about which babies will have worse symptoms of withdrawal (i.e., require more medication and remain in the hospital longer). Women commonly worry about increasing doses of their medication (methadone, buprenorphine) because they fear that a higher dose will lead to worse withdrawal symptoms in babies. However, studies have shown that the dose does not correlate with the severity of withdrawal.3 There is some evidence that babies exposed to buprenorphine have less severe withdrawal than those exposed to methadone in utero.5 And, newer research is coming out that shows that genes probably play a significant role in the severity of withdrawal, independent of other factors.12 Finally, many people don’t realize that tobacco, benzodiazepines, selective serotonin reuptake inhibitors (SSRIs), gabapentin, and other substances have been shown to increase the severity of neonatal withdrawal, and that much of the more severe symptoms we see in neonates is likely a combination of genetic predisposition and multiple exposures.11
The bottom line is:
- Experts recommend mothers stay on maintenance treatment (methadone, buprenorphine) for their opioid use disorder to prevent relapse or other consequences of drug use in pregnancy.
- Babies cannot be born “addicted”
- Neonatal withdrawal from opioids is a treatable, time-limited, and expected outcome for opioid exposure in utero.
HMS CME Online offers free Opioid Use Disorder Education courses that have been approved for 16 MAT-waiver training hours for nurses and nurse practitioners.
- American College of Obstetrics and Gynecology. 2017. “Committee Opinion No 711: Opioid Use Disorder in Pregnancy”. Obstet Gynecol. 2017; 130(2):e81.
- Botticelli, Michael. 2017. “Office of National Drug Control Policy Changing the Language of Addiction Background.”
- Cleary BJ, Donnelly J, Strawbridge J, Gallagher PJ, Fahey T, Clarke M, Murphy DJ. 2010. “Methadone Dose and Neonatal Abstinence Syndrome-Systematic Review and Meta-Analysis.” Addiction 105 (12):2071–84. https://doi.org/10.1111/j.1360-0443.2010.03120.x
- Grossman, Matthew R, Adam K Berkwitt, Rachel R Osborn, Yaqing Xu, Denise A Esserman, Eugene D Shapiro, and Matthew J Bizzarro. 2017. “An Initiative to Improve the Quality of Care of Infants With Neonatal Abstinence Syndrome.” Pediatrics 139 (6). American Academy of Pediatrics:e20163360. https://doi.org/10.1542/peds.2016-3360.
- Jones, Hendrée E, Sarah H Heil, Andjela Baewert, Amelia M Arria, Karol Kaltenbach, Peter R Martin, Mara G Coyle, Peter Selby, Susan M Stine, and Gabriele Fischer. 2012. “Buprenorphine Treatment of Opioid-Dependent Pregnant Women: A Comprehensive Review.” Addiction (Abingdon, England) 107 Suppl (0 1). NIH Public Access:5–27. https://doi.org/10.1111/j.1360-0443.2012.04035.x.
- Jones HE, O’Grady KE, Malfi D, Tuten M, 2008. ” Methadone maintenance vs. methadone taper during pregnancy: maternal and neonatal outcomes.: Am J Addiction 2008; 17(5):372. doi: 10.1080/10550490802266276.
- Kelly, John F., Sarah E. Wakeman, and Richard Saitz. 2015. “Stop Talking ‘Dirty’: Clinicians, Language, and Quality of Care for the Leading Cause of Preventable Death in the United States.” American Journal of Medicine 128 (1). Elsevier Inc.:8–9. https://doi.org/10.1016/j.amjmed.2014.07.043.
- Kelly, John F., and Cassandra M. Westerhoff. 2010. “Does It Matter How We Refer to Individuals with Substance-Related Conditions? A Randomized Study of Two Commonly Used Terms.” International Journal of Drug Policy 21 (3). Elsevier:202–7. https://doi.org/10.1016/J.DRUGPO.2009.10.010.
- Ko, Jean Y, Stephen W Patrick, Van T Tong, Roshni Patel, Jennifer N Lind, and Wanda D Barfield. 2016. “Incidence of Neonatal Abstinence Syndrome – 28 States, 1999-2013.” MMWR. Morbidity and Mortality Weekly Report 65 (31):799–802. https://doi.org/10.15585/mmwr.mm6531a2.
- Lyoom IK, Pollack MH, Silveri MM, Ahn KH et al. 2006. “Prefrontal and temporal gray matter density decreases in opiate dependence”. Psychopharmacology (Berl), 2006; 184(2): 139.
- Wachman, Elisha M., A. Hutcheson Warden, Zoe Thomas, Jo Ann Thomas-Lewis, Hira Shrestha, F.N.U. Nikita, Daniel Shaw, Kelley Saia, and Davida M. Schiff. 2018. “Impact of Psychiatric Medication Co-Exposure on Neonatal Abstinence Syndrome Severity.” Drug and Alcohol Dependence 192 (November):45–50. https://doi.org/10.1016/j.drugalcdep.2018.07.024.
- Wachman, Elisha M, Marie J Hayes, Mark S Brown, Jonathan Paul, Karen Harvey-Wilkes, Norma Terrin, Gordon S Huggins, Jacob V Aranda, and Jonathan M Davis. 2013. “Association of OPRM1 and COMT Single-Nucleotide Polymorphisms with Hospital Length of Stay and Treatment of Neonatal Abstinence Syndrome.” JAMA 309 (17). United States:1821–27. https://doi.org/10.1001/jama.2013.3411.
- Wu, Danwei, and Camille Carre. 2018. “The Impact of Breastfeeding on Health Outcomes for Infants Diagnosed with Neonatal Abstinence Syndrome: A Review.” Cureus 10 (7):e3061. https://doi.org/10.7759/cureus.3061.
- Zelder BK, Mann AL, Kim MM, Amick HR et al. 2016. “Buprenorphine compared with methadone to treat pregnant women with opioid use disorder: a systematic review and meta-analysis of safety in the mother, fetus and child”. Addiction. 2016; 111(12):2115. doi: 10.1111/add.13462.
Dr. Sarah Bernstein is a high-risk pregnancy specialist board certified in both maternal fetal medicine and obstetrics and gynecology at Massachusetts General Hospital and a clinical instructor at Harvard Medical School. Dr. Bernstein is the medical director of the obstetrics clinic at MGH as well as the obstetrics director of the HOPE Clinic, a multidisciplinary clinic that provides care for pregnant and parenting women with substance use disorders. Dr. Bernstein is passionate about optimizing care for pregnant women with substance use disorders and advancing research in this area.
Dr. Jessica Gray is a family medicine physician and addiction specialist in the departments of Medicine at Massachusetts General Hospital (MGH) and Pediatrics in MGHfC. She is associate program director for the MGH Addiction Medicine Fellowship and clinical director of the HOPE Clinic at MGH, where she cares for women with substance use disorders and their families from time of conception through the first two years postpartum. She also sees patients at the MGH Bridge Clinic, a low-threshold outpatient substance use treatment clinic, and is a consultant with the Massachusetts Consultation Service for Treatment of Addiction and Pain (MCSTAP) team, which provides support for primary care providers treating patients with chronic pain and/or substance use disorder.
*OPINIONS EXPRESSED BY OUR GUEST AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.