Frequently Asked Questions

It is now more feasible for jails to provide methadone due to DEA regulation changes. See here for details.

It is not advisable to switch a pregnant patient from methadone to buprenorphine because it may cause withdrawal symptoms that could harm the mother and the developing fetus. Continuing the existing treatment with methadone, if medically appropriate, is usually recommended to ensure consistent care and avoid complications. If buprenorphine is the only option, a clinician with pregnancy and addiction medicine expertise should be consulted.

Switching a pregnant patient from buprenorphine to methadone without proper clinical guidance could cause withdrawal symptoms and health complications. It’s best to continue with the patient’s existing buprenorphine treatment. Additionally, it’s very feasible to add buprenorphine to your formulary since providers no longer need an additional X-waiver license to prescribe it. This flexibility allows for continued, effective care for the patient, ensuring stability and minimizing risks to the mother and baby.

Sublocade is not recommended during pregnancy because it is an injectable and pregnant patients typically need frequent dose adjustments as the pregnancy progresses. Instead, methadone and other forms of buprenorphine (e.g. suboxone and subutex) are advised.

While naltrexone is commonly used among non-pregnant individuals with opioid use disorder, it is generally not recommended to be used in pregnancy. There is limited safety data regarding the use of naltrexone in pregnancy. If an individual becomes pregnant while taking naltrexone, they should consult their treatment provider about whether to continue it or switch medication. See MOMCARE Pros and Cons of Methadone and Buprenorphine in Pregnancy

It depends! For some patients, methadone works better for their recovery, and for others, buprenorphine does. Studies have shown that babies born to moms taking buprenorphine may have less severe neonatal opioid withdrawal symptoms (NOWS). However, getting the patient on a medication that works for them is most important, so care should be individualized, and pregnant patients should have a choice. See this TABLE on the pros and cons of methadone and buprenorphine in pregnancy.

In order to initiate buprenorphine, patients must have some withdrawal symptoms to avoid inducing precipitated withdrawal. Avoiding chronic, repeated opioid withdrawal is important to protect the health of the pregnant patient and fetus. However, acute, time-limited withdrawal to start buprenorphine is safe in pregnancy. Review this protocol for starting buprenorphine in pregnancy and  watch this short, 5-minute MOMCARE video for further guidance. 

No. These medications have been studied in pregnancy and have not been associated with an increased risk of birth defects.

Many illicit drug supplies these days are laced with fentanyl and/or Xylazine. Fentanyl is 50 times stronger than heroin; Xyzlazine is an animal tranquilizer. Both of these medications can make withdrawal management and MOUD initiation in pregnancy more challenging and may require offsite management and hospital-level care. 

Although MOUD is the standard of care for pregnant individuals with opioid use disorder, patients have the right to decline treatment and may do so even after receiving thorough counseling. An individual may be more likely to refuse MOUD when they feel pressured into it or if they have not received enough information. If a pregnant patient refuses to be on MOUD, providers should treat withdrawal symptoms with methadone or buprenorphine and utilize the best practices outlined in Initial Care.

No, medications should not be withheld. MOUD (also referred to as MAT) is an effective standalone treatment for opioid use. However, access to support services, including counseling and behavioral health care, is helpful for recovery. But no patient on MOUD should be forced into counseling. 

Yes, naloxone is a life-saving tool that should be administered to pregnant patients in cases of opioid overdose. Naloxone is a short-acting opioid blocker that can reverse an opioid overdose if used in time. Naloxone can cause withdrawal symptoms. However, withdrawal symptoms can be managed with pregnancy-safe medications.

We generally recommend that pregnant patients with OUD be in a hospital setting to start MOUD, where providers can ensure MOUD stabilization, monitor withdrawal symptoms, manage any obstetric issues that arise, provide fetal monitoring, and connect individuals to community resources upon release. However, not all pregnant patients with OUD need to be in a hospital setting to initiate MOUD. It is generally appropriate to manage a newly admitted pregnant patient with OUD onsite at the jail if:

1. The patient is well-appearing and demonstrates no urgent maternal warning signs
2. The jail has sufficient medical care capacity to dose MOUD, including qualified staff who can initiate medication, provide pregnancy withdrawal care, and quickly assess when more extensive care is required
3. The patient declines hospital transport

See Initial Care and When to Transport 

No! A drug test is not a parenting test. If someone screens positive, this does not mean they cannot parent, but they should be referred for services. And, being in jail while pregnant does not mean a person is a bad parent.

A positive urine drug screen isn’t required before initiating MOUD. National guidelines recommend screening through patient history and questions rather than urine drug tests, which are not always accurate and can have delayed results. Comprehensive clinical assessment ensures appropriate treatment based on opioid use disorder symptoms and personal history. 

Yes! Breastfeeding while on MOUD is safe and recommended for infant health. When possible, allow postpartum patients to directly breastfeed their infants at contact visits or make arrangements to store and transport breastmilk to the infant. The breastmilk will have a very small amount of MOUD in it that is not harmful to the infant and will help with neonatal opioid withdrawal syndrome (NOWS).

No! Pregnant patients who have been caught diverting medications should not have their MOUD discontinued. Jail staff should discuss the concern with the patient and use an alternative protocol for dosing.

Here is a step-by-step pathway that guides you on what to do if you discover someone has diverted. Note that this pathway is not specific to pregnancy, so the naltrexone and injectable buprenorphine recommended in this pathway should not be used.

You can’t! Diagnosing labor requires special training to see how dilated someone’s cervix is. Some women will have very painful contractions, others will have mild pain. Some people will have light bleeding or leaking fluid, others will not. Jail staff must have a low threshold to refer pregnant patients with possible labor symptoms for evaluation. See our infographic on signs of labor.  

NO! Once a pregnant patient on MOUD gives birth (or her pregnancy ends for another reason), MOUD should be continued during the postpartum period unless the individual requests otherwise. The MOUD dosage will likely need to be adjusted postpartum which should be assessed by an experienced clinician in conversation with the patient. 

In the case of discontinuation, the individual should be counseled about the risks of cessation, and together the patient and provider should develop a plan to gradually taper the medications over time. Patients should never be withdrawn “cold turkey” from MOUD.

Nalmefene (brand name Opvee) is a newer opioid reversal medication, but it has not been studied in pregnancy. Naloxone (Narcan) remains the recommended and safest option for reversing opioid overdoses in pregnant individuals. 

Nalmefene is being marketed to jails and prisons because of its longer duration of action, which some believe may be helpful for fentanyl overdoses. But there is no strong evidence that it works better than naloxone. And because it stays in the body much longer, it can cause more intense and longer-lasting withdrawal, which is harder to manage—especially during pregnancy.  

There are no human studies on the safety of nalmefene in pregnancy. That means the safest approach is to continue using naloxone for anyone who might be pregnant.