Initial Care

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Initial Care Steps, Opioid Use In Pregnancy

Once you identify a pregnant patient with OUD in your custody, use these initial steps to guide decisions about whether they need to be transported off-site or can stay in jail to start or continue methadone or buprenorphine, and how to manage withdrawal symptoms in pregnancy.

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Initial Care Steps, Opioid Use In Pregnancy

HOW

  • Assess whether the pregnant patient can remain at the jail or should be transported to a hospital. Consider the patient’s condition (e.g. do they appear unwell?), the jail’s capacity to start or continue MOUD (e.g. do you have the meds available? Is there a qualified health professional on site?), and the local hospital’s capacity to treat the patient (e.g. is the hospital equipped to provide OUD and obstetrical care?) 
  • If the pregnant patient is already on MOUD upon jail arrival, verify dose and continue it! 
    • Avoid switching from one medication to another, especially from methadone to buprenorphine. Naltrexone is generally avoided in pregnancy. 
  • If the pregnant patient is not on MOUD at intake, provide pregnancy-specific counseling and start MOUD, either onsite or offsite, depending on patient condition, jail capacity and hospital capacity. 
    • Here is a protocol for buprenorphine initiation in pregnancy. It is safe for a pregnant patient to experience short-term, acute withdrawal before initiating buprenorphine to avoid precipitated withdrawal. Watch this short 5-minute MOMCARE video for further guidance on starting buprenorphine in pregnancy. 
    • Here is a protocol for methadone initiation. While it is not specific to pregnancy, the main additions would be to assess for urgent maternal warning signs, provide pregnancy-specific counseling to patients, and that they may need inpatient care.
  • If there is a delay in providing the pregnant patient’s MOUD dose, treat withdrawal symptoms with pregnancy-safe medications for symptom relief. See table for Safe Medications for Managing Opioid Withdrawal in Pregnancy.
  • If a pregnant person declines MOUD, provide medically supervised withdrawal with methadone or buprenorphine and other pregnancy-safe medications for symptom relief (see TABLE), either onsite or offsite depending on patient condition, jail capacity, and hospital capacity. 


WHY

  • MOUD with methadone and buprenorphine (with and without naloxone) is safe in pregnancy; withdrawal is not. 
  • All pregnant patients who use opioids should be offered MOUD and counseled about being on MOUD while pregnant (e.g. dose adjustments, fetal wellbeing, risk of newborn withdrawal symptoms, risks of detox in pregnancy, breastfeeding, etc.).
  • Switching from one medication to another, especially methadone to buprenorphine, should be avoided in pregnancy. 


KEEP IN MIND 

  • Pregnant patients want what’s best for their babies, even when they exhibit behaviors that may seem harmful. Some patients may be afraid of MOUD side effects or of losing custody of their baby.
  • Keep the patient informed on their treatment and respect autonomy in treatment decisions. Provide patient education materials as needed. See MOMCARE Patient Education Resources –  MOMCARE Treatment for OUD during Pregnancy and Postpartum patient education 1-pager
  • Review the urgent maternal warning signs and educational materials on being pregnant/postpartum with OUD with patients. Educate your patients about these symptoms so they are aware while in jail and in the community. 
  • Connect the patient to behavioral health treatment and recovery support, either in jail or through partnerships with a community treatment provider.
  • Methadone and buprenorphine doses often need to be increased or split as pregnancy progresses. Ensure that the patient has frequent follow-ups with a treatment provider who can assess the need for dose adjustments.
  • Screen for perinatal anxiety with a validated instrument, such as the Perinatal Anxiety Screening Scale.
  • Provide ongoing support and encouragement—recovery is a hard process!
  • Call the National Clinician Consultation Center Substance Use Warmline to speak to a clinician for advice and clinical guidance as needed (855) 300-3595. (not for patients)


See other MOMCARE Ongoing MOUD Care and Reentry Planning

HOW

How to determine if the pregnant patient is well enough to stay in jail.

  • The person doing the initial medical intake should determine if the pregnant patient with OUD appears “UNWELL.” If they are unwell, then they need an immediate clinical assessment by a qualified health care professional—a physician or advanced practice clinician with experience treating pregnant patients with substance use. This typically needs to happen in the hospital.

“Unwell” means that someone has observed signs and symptoms that are obvious to a layperson that they are physically or psychologically sick, including signs of self-reported intoxication or substance withdrawal. For a pregnant person, this also includes signs or symptoms of labor or urgent maternal warning signs, like bleeding, pelvic pain, severe headache, contractions, and others.

When is it appropriate to manage a new pregnant patient with OUD onsite at the jail?

  • If the pregnant patient is well-appearing and has no urgent maternal warning signs, AND
  • If the jail has medical care capacity to dose methadone and buprenorphine including qualified, trained medical staff who are comfortable initiating pregnant patients on MOUD, managing withdrawal symptoms, and can recognize when a higher level of care is necessary for pregnant patients, OR
  • If the pregnant patient declines hospital transport.

If the pregnant patient is already on methadone or buprenorphine upon arrival, CONTINUE IT!

  • Find out where they get their dose, and verify what their dose is. Ask them when their last dose was. Document it in the jail medical record that you verified this information.
  • She should get her next dose within 24 hours of when it is due. Do not delay continuing the dose they were on in the community.
    • If there is going to be a delay of more than 24 hours, treat withdrawal symptoms with pregnancy-safe medications (see Table). We generally recommend avoiding opioids that are not methadone/buprenorphine for withdrawal symptoms (e.g. oxycodone, hydromorphone, Tylenol#3). However, there may be times when it is appropriate to dose with these for symptom relief.
    • If they have missed 1-2 days of doses, give their full dose. If they have missed 3 or more doses, ask a qualified provider for advice—they may need to start at a lower dose and work up to their prior dose.
    • Methadone– If you do not provide methadone on-site at your jail or you cannot obtain it for a few days, you will need to make alternate arrangements for the next methadone dose. You can use the “DEA 3 Day Rule” to provide methadone until you can make a long-term plan. Alternatively, jails that are registered with the DEA as a clinic/hospital can now provide methadone to pregnant patients! See MOMCARE MOUD/MAT Delivery Models
    • Buprenorphine- Physicians, Nurse Practitioners, and Physician Assistants who have a standard DEA license can now prescribe buprenorphine. No additional waiver is necessary. Thus, jails should stock buprenorphine on their formulary and store it as they would any other Schedule 3 drug. 
      • Both the monoproduct (Subutex) and combined (Suboxone) are safe in pregnancy

You should avoid switching pregnant patients from one medication to another. 

  • The other medication may not work for them and can lead to relapse.
  • Switching from methadone to buprenorphine can cause severe withdrawal, and is not recommended in pregnancy.
  • If switching is unavoidable (i.e. if your jail can only provide one medication that is different from what the patient was taking before jail), it should only be done by an experienced provider and usually in a hospital setting.

If the pregnant patient was not on MOUD before arriving at the jail, COUNSEL AND START MOUD TREATMENT WITH METHADONE OR BUPRENORPHINE

  • Counsel pregnant patients with OUD on the benefits of treatment in pregnancy, risks of going through withdrawal in pregnancy, and what to expect for their newborn. If you are unable to answer their questions, tell them you’ll refer them to someone who can. 
  • Any prescriber with a DEA license can initiate buprenorphine in pregnancy. While the prescriber does not need to have training in obstetrical care, they should have training to recognize when a pregnant patient getting stabilized on MOUD needs obstetrical evaluation. 
  •  Methadone initiation in pregnancy is often best accomplished by providers with obstetrical and OUD expertise.
  • Which medication a pregnant patient should be started on should be individualized. This table can help patients choose a medication by weighing the pros and cons of methadone and buprenorphine in pregnancy. For jail programmatic considerations of methadone vs. buprenorphine in jail, see MOMCARE MOUD/MAT Delivery Models.
  • Here is a protocol for buprenorphine initiation in pregnancy
  • Here is a protocol for methadone initiation. While it is not specific to pregnancy, the main additions would be to assess for urgent maternal warning signs, provide pregnancy-specific counseling to patients, and that they may need inpatient care.

Treat withdrawal symptoms while waiting for transport to the hospital and/or while waiting for consultation with a clinician if the jail is equipped to provide pregnancy withdrawal care on-site, or if the patient declines treatment and hospital transport.

What dose should a pregnant patient be started on? 

  • A common starting dose for methadone in pregnancy is 30mg and for buprenorphine is 8-16mg, with titration according to standard protocols.
  • Here is a protocol for buprenorphine initiation in pregnancy. It is safe for a pregnant patient to experience shot-term, acute withdrawal before initiating buprenorphine to avoid precipitated withdrawal. Watch this short 5-minute MOMCARE video for further guidance on starting buprenorphine in pregnancy. 
  • Here is a protocol for methadone initiation. While it is not specific to pregnancy, the main additions would be to assess for urgent maternal warning signs, provide pregnancy-specific counseling to patients, and that they may need inpatient care.


Is fetal monitoring required during methadone/buprenorphine initiation?

No, unless there are other obstetric indications for monitoring (e.g. contractions or other maternal conditions). It is a good idea, however, to document the presence of fetal heart tones in a patient who is in the 2nd or 3rd trimester using a portable Doppler machine at the jail, if you have a medical staff member qualified to assess this.


What about Naltrexone to treat opioid use? 

Generally, naltrexone is not recommended in pregnancy. However, if a person becomes pregnant while on naltrexone, the decision of whether to continue or switch should be made with their treatment provider. 


What if the pregnant patient declines MOUD?

  • While MOUD is the standard of care in pregnancy, patients have the right to decline, after thorough counseling.
  • Patients are less likely to continue MOUD when they feel pressured into it and when they feel they have not received enough information. 
  • Treat withdrawal symptoms. See table for Safe Medications for Managing Opioid Withdrawal in Pregnancy.


What do I need to know about medically-supervised withdrawal from opioids in pregnancy? 

Medically supervised withdrawal in pregnancy should only be done after the patient has received full counseling on the risks and should be done at a location with adequate hydration, quiet, rest, and where there is staff familiar with managing withdrawal in pregnancy.


What medications are safe to use when treating withdrawal symptoms in pregnancy?

  • Methadone and buprenorphine are first-line treatments for managing withdrawal symptoms, including in pregnancy, even if ongoing treatment will not be initiated.
  • See the table below for which other medications are safe to use in pregnancy for symptom management during withdrawal.
  • Access to frequent hydration is especially important in pregnancy.
  • We DO NOT recommend using oxycodone, codeine, hydromorphone, or other non-methadone/bupe opioid medications to treat withdrawal symptoms or as a long-term treatment for OUD. Furthermore, the DEA does not authorize the use of these medications for withdrawal management. On occasion, addiction specialists will use these medications for symptom management while stabilizing on a dose of methadone/bupe, but we do not recommend jail staff use these for withdrawal management.


WHY 

OUD is a chronic disease and is best treated with medications, along with behavioral health and social resource assistance.

Medications for Opioid Use Disorder (MOUD) in Pregnancy 

Opioid Withdrawal in Pregnancy 
  • The standard of care is to treat opioid use in pregnancy with methadone or buprenorphine.
  • Safe in pregnancy
  • Promote maternal and fetal health, and recovery
  • Are safe for the fetus
  • Decreases the risk of maternal death, preterm birth, stillbirth, overdose (by 70%!), and HIV and hepatitis. 
  • Unsafe in pregnancy—for both the fetus and the pregnant individual. 
  • Associated with:
    • Return to use and overdose.
    • Increased risks of preterm birth, low birth weight, infections for the fetus/infant, and possible association with pregnancy loss.
    • Extreme dehydration.
  • Some pregnant patients may be hesitant to start methadone or buprenorphine, in part because they are concerned about what effect it will have on their fetus and newborn. Counseling that is attentive to these concerns is essential to their treatment success (see Counseling Pearls). 
  • Some patients prefer one medication over the other, or there may be other reasons why one is preferred. Having both available, if possible, is ideal. 
    • For help with deciding which medication to prioritize, see MOMCARE MOUD/MAT Delivery Models.
  • Pregnant patients already on medication should NOT switch, especially from methadone to buprenorphine (this can put them into precipitated withdrawal) so it’s important to have a backup plan.
  • There may be legal consequences for jails that do not provide MOUD in pregnancy, based on state laws, and need to comply with the Americans with Disabilities Act. See MOMCARE Legal and Regulatory. 

 

Why does treatment matter so much? 

  • Treating just 20 pregnant people with buprenorphine prevents 1 serious complication, like preterm birth, NICU stay, or death.  

  • That’s a bigger impact than many other treatments we provide for other health conditions. Every pregnant person who uses opioids deserves access to this care 


Do pregnant patients with OUD need to go to the hospital or can they stay at the jail to start MOUD? What about for withdrawal management?

  • We generally recommend methadone or buprenorphine initiation and withdrawal management for pregnant patients in a hospital setting for many reasons: 
    • Stabilization can be trickier in pregnancy since pregnant patients metabolize medications more quickly.
    • MOUD stabilization can be trickier with the widespread use of fentanyl and Xylazine.
    • Symptoms of withdrawal can be hard to distinguish from other pregnancy concerns, like preterm labor
    • Withdrawal in pregnancy may cause some obstetric issues like contractions, and many jails are not equipped to evaluate these things on-site. 
    • Allows for fetal monitoring if indicated, and connection to community services that they will need when they are released.
  • While waiting for transport to the hospital to start MOUD, it is important to treat withdrawal symptoms to avoid extreme discomfort and minimize risks to the pregnancy.
  • Bottom line: A pregnant patient who appears “unwell” should be immediately referred for assessment by a qualified clinician, a physician, or an advanced practice clinician with experience treating pregnant patients with substance use. Usually, this means transport to the hospital.

Broadly defined, “appears unwell” encompasses observed signs and symptoms obvious to a layperson that:

  •  An individual may be sick (physically or psychologically), which includes signs of or self-reported intoxication or substance withdrawal. Symptoms of the latter may present at any time (including upon arrival to the facility); typically, they emerge within 72 hours of arrival.

For pregnant patients, “unwell” also includes urgent maternal warning signs.


When is it appropriate for the jail to manage a new pregnant patient with OUD on site? 

This depends on the jail’s medical care capacity, the patient’s status, and the services available at the local hospital. Here are some conditions for on-site management:

  • The jail has access to 24/7 consultation with a clinician with experience with both MOUD AND pregnancy care (i.e. obstetrician, family physician, midwife, NP/PA with special training), either in person, via telehealth, or by phone.
    • Jail has medical staff who are experienced in managing pregnancy withdrawal symptoms and can recognize when a higher level of care is necessary.
  • Jail health care staff are trained in MOUD induction protocols, withdrawal management, and emergency pregnancy warning signs, with the capacity for frequent assessment and methadone/buprenorphine dose adjustments.
    • Protocols for on-site management should include guidance on ongoing monitoring and care, including a qualified healthcare staff to monitor vital signs and OUD (e.g. COWS)  and pregnancy symptoms.
  • The ability to dose methadone or buprenorphine on-site, and to give patient choice of medication.
  • Low threshold to transport patients off-site for further assessment and management.
  • Access to physical space for the patient that will allow rest, quiet, and 24/7 access to potable water or electrolyte solution.
  • If the pregnant patient is well-appearing and has no urgent maternal warning signs.
  • If the pregnant patient declines hospital transport.

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