23
Î Drug and alcohol testing should be used to monitor patients
for adherence to medication and for use of illicit and controlled
substances.
• This should be done with informed consent from the mother, realizing that there
may be adverse legal and social consequences for substance use.
• State laws differ on reporting substance use during pregnancy. Laws that penalize
women for substance use and for obtaining treatment serve to prevent women
from obtaining prenatal care and worsen outcomes.
• For further clarity see The ASAM Appropriate Use of Drug Testing in Clinical
Addiction Medicine
4
guidance document.
Î Care for pregnant women with OUD should be comanaged by a
clinician experienced in obstetrical care and a clinician experienced
in the treatment of OUD.
Î Hospitalization during initiation of methadone or buprenorphine may
be may be an option for those with co-morbid medical or psychosocial
issues due to the potential for adverse events, especially in the third
trimester.
Î MAJOR REVISION – Methadone should be initiated at a dose range of
10–30mg. Incremental doses of 5–10mg is recommended every 3–6
hours, as needed, to treat withdrawal symptoms, to a maximum first
day dose of 30–40mg.
Î MAJOR REVISION – After initiation, clinicians should increase the
methadone dose by no more than 10mg approximately every 5 days.
The goal is to maintain the lowest dose that controls withdrawal
symptoms and minimizes the desire to use additional opioids.
Î Clinicians should be aware that the pharmacokinetics of methadone
are affected by pregnancy.
• With advancing gestational age, plasma levels of methadone progressively decrease
and clearance increases.
• Increased and/or split doses may be needed as pregnancy progresses.
• At least twice-daily dosing is more effective and has fewer side effects than single
dosing but may not be practical because methadone is typically dispensed in an OTP.
• After childbirth, doses will need to be adjusted (typically reduced) based on
changes in weight and metabolism.
Î MAJOR REVISION – If a woman becomes pregnant while she is receiving
naltrexone, it may be appropriate to discontinue the medication if the
patient and clinician agree that the risk of relapse is low.
• A decision to remain on naltrexone during pregnancy should be carefully
considered by the patient and her clinician and should include a discussion on the
insufficiency of research on risks (if any) of continued use of naltrexone.
• If the patient chooses to discontinue treatment with naltrexone and is at risk for
relapse, treatment with methadone or buprenorphine should be considered.
