14
Treatment
Special Populations
Pregnant Women
Î The first priority in evaluating pregnant women for OUD should be to
identify emergent or urgent medical conditions that require immediate
referral for clinical evaluation.
Î A medical examination and psychosocial assessment is recommended
when evaluating pregnant women for OUD.
Î Obstetricians and gynecologists should be alert to signs and
symptoms of OUD.
• Pregnant women with OUD are more likely to seek prenatal care late in
pregnancy, miss appointments, experience poor weight gain, or exhibit signs of
withdrawal or intoxication.
Î Psychosocial treatment is recommended in the treatment of pregnant
women with OUD.
Î Counseling and testing for HIV should be provided in accordance with
state law. Tests for hepatitis A, B and C and liver function are also
suggested.
• Hepatitis A and B vaccination is recommended for those whose hepatitis serolog y
is negative.
Î Urine drug testing may be used to detect or confirm suspected opioid
and other drug use with informed consent from the mother, realizing
that there may be adverse legal and social consequences of her use.
• State laws differ on reporting substance use during pregnancy. Laws that penalize
women for use and for obtaining treatment serve to prevent women from
obtaining prenatal care and worsen outcomes.
Î Pregnant women who are physically dependent on opioids should
receive treatment using methadone or buprenorphine monoproduct
rather than withdrawal management or abstinence.
Î Treatment with methadone should be initiated as early as possible
during pregnancy.
• Hospitalization during initiation of methadone and treatment with
buprenorphine may be advisable due to the potential for adverse events, especially
in the third trimester.
• In an inpatient setting, methadone should be initiated at a dose range of
20–30 mg. Incremental doses of 5–10 mg are given every 3–6 hours, as needed,
to treat withdrawal symptoms.
• After induction, clinicians should increase the methadone dose in 5–10 mg
increments per week. The goal is to maintain the lowest dose that controls
withdrawal symptoms and minimizes the desire to use additional opioids.
• 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 outpatient clinic.
