Opioids During Pregnancy: Risks, Withdrawal, and Monitoring

When a pregnant person is using opioids, whether prescribed or not, the stakes aren’t just about their own health-they’re about the life growing inside them. Opioid use disorder (OUD) during pregnancy isn’t rare. Between 2010 and 2020, cases of neonatal opioid withdrawal syndrome (NOWS), formerly called NAS, increased fivefold in U.S. hospitals. That’s not just a statistic. It’s a wave of babies born with trembling hands, high-pitched cries, and trouble eating-each one needing care that’s more complex than most new parents expect.

What Happens When Opioids Cross the Placenta

Opioids don’t stay in the mother’s bloodstream. They cross the placenta easily, reaching the baby’s developing brain and nervous system. That’s why babies exposed to opioids before birth often go into withdrawal after birth. It’s not because the mother did something wrong-it’s because the baby’s body has adapted to the drug’s presence and now has to adjust without it.

The symptoms of neonatal opioid withdrawal syndrome (NOWS) can show up as early as 48 hours after delivery. Common signs include:

• High-pitched, persistent crying
• Shaking or twitching limbs
• Feeding problems-difficulty latching, vomiting, poor weight gain
• Fast breathing (over 60 breaths per minute)
• Temperature changes-either too high or too low
• Loose, watery stools (more than three per hour)

These symptoms aren’t just uncomfortable-they can be dangerous. About 50% to 80% of babies exposed to opioids during pregnancy will need medical help for withdrawal. That’s why monitoring starts the moment the baby is born.

Why Withdrawal Isn’t the Answer

Many people assume the best thing to do is stop opioids during pregnancy. But stopping suddenly-called medically supervised withdrawal-isn’t safer. In fact, it’s riskier.

The CDC says that pregnant people who try to quit opioids cold turkey face a 30% to 40% higher chance of relapse. That means they’re more likely to use again, often at higher doses, which puts the baby at even greater risk. Withdrawal also increases the chances of:

• Preterm labor (25-30% vs. 15-20% with treatment)
• Fetal distress (18-22% vs. 8-12% with treatment)
• Miscarriage (5-8% vs. 2-4% with treatment)

Instead of quitting, the standard of care is medication-assisted treatment (MAT). That means using FDA-approved medications like methadone or buprenorphine to keep the mother stable-without the highs and lows of street drugs or misuse.

Methadone vs. Buprenorphine: What’s the Difference?

Not all MAT is the same. Two medications are most commonly used: methadone and buprenorphine. Both are safe during pregnancy, but they have different effects.

Methadone is a full opioid agonist. It’s been used for decades in pregnancy. Dosing usually starts at 10-20 mg per day and can go up to 60-120 mg, depending on the person’s needs. It has high retention rates-70% to 80% of people stay in treatment after six months. But babies born to mothers on methadone often have more severe withdrawal symptoms. On average, their hospital stays are longer-about 17.6 days-and their Finnegan scores (a tool doctors use to measure withdrawal severity) are higher, averaging 14.3.

Buprenorphine is a partial opioid agonist. It’s newer in pregnancy care but widely recommended now. Starting doses are lower-2-4 mg daily-and can go up to 8-24 mg. It’s easier to manage, often given as a sublingual film. Babies exposed to buprenorphine have less severe withdrawal than those exposed to methadone. Their average Finnegan score is 11.8, and hospital stays are shorter-around 12.3 days. But here’s the catch: 46% of these babies still need medication to treat withdrawal.

One study from Boston Medical Center found that infants exposed to naltrexone-a medication that blocks opioids-had zero cases of withdrawal. That sounds perfect, right? But naltrexone isn’t used for everyone. The mothers in that study got into treatment much later-on average at 28.4 weeks-compared to 19.7 weeks for those on buprenorphine. Delayed care means higher risk for the baby. So while naltrexone looks promising, it’s not a first-line option unless the person is already stable and far along.

How Babies Are Monitored After Birth

Every baby born to a mother with OUD needs careful monitoring. The CDC recommends at least 72 hours of observation, with checks every 3-4 hours in the first day, then every 4-6 hours after that.

Most hospitals use the Finnegan scale-a checklist that scores symptoms like crying, tremors, sleep, and feeding. But not all hospitals use the same tool. One study found 37 different scoring systems in use across U.S. hospitals. That’s confusing for families and inconsistent for care.

More hospitals are switching to the Eat, Sleep, Console method. Instead of focusing only on symptoms, this approach asks: Can the baby eat? Can they sleep? Can they be comforted? If the answer is yes to all three, they might not need medicine-even if their Finnegan score is high. Hospitals using this method report 30-40% fewer babies needing opioid treatment for withdrawal.

Can You Breastfeed While on Opioid Treatment?

Yes-most of the time. Breastfeeding is encouraged for mothers on methadone or buprenorphine. The amount of medication that passes into breast milk is very low and doesn’t usually cause problems. In fact, breastfeeding can help reduce the severity of withdrawal symptoms in babies.

One study showed that 83% of mothers on naltrexone were able to breastfeed without issues. For those on buprenorphine, breastfeeding rates are high too, but some babies still need extra monitoring. The American Academy of Pediatrics says breastfeeding is safe for most infants on MAT unless the mother is using other substances or has HIV.

Still, many moms report stigma. One mother on a recovery forum said her nurse told her, “You shouldn’t be nursing-you’re still using drugs.” That kind of comment isn’t just hurtful-it’s wrong. MAT isn’t “using.” It’s treatment.

What About New Treatments?

In 2023, the FDA approved a new long-acting form of buprenorphine called Brixadi. It’s given as a monthly injection instead of daily pills or films. In early trials, 89% of pregnant women stayed in treatment for 24 weeks-compared to 76% with daily buprenorphine. That’s a big win. Keeping people in treatment longer means better outcomes for both mom and baby.

Another promising shift is in how we treat withdrawal. The American Academy of Pediatrics now says: Try non-drug care first. Hold the baby skin-to-skin. Rock them. Feed them often. Dim the lights. These simple things can calm a baby’s nervous system. Only if those don’t work should doctors consider medication like morphine or methadone for the baby.

The Bigger Picture: Why This Isn’t Just About Medicine

Treating OUD during pregnancy isn’t just about pills and monitoring. It’s about access. In 2021, only 45% of U.S. hospitals had a standard protocol for managing OUD in pregnancy. In rural areas, that number drops to 28%. Many women don’t get care until late in pregnancy-sometimes not until they’re in labor.

And it’s not just about drugs. Nearly half of pregnant women with OUD face housing instability. More than 30% have moderate to severe depression. Over 40% report postpartum depression. Without mental health support, housing help, and trauma-informed care, even the best medication won’t work.

Programs that tie together prenatal care, MAT, therapy, and housing assistance are showing results. One NIH-funded study found that when all these pieces are connected, NAS severity drops by 22%. That’s not magic. That’s good care.

What You Need to Know If You’re Pregnant and Using Opioids

If you’re pregnant and using opioids-whether prescribed, misused, or taken recreationally-here’s what matters most:

1. Don’t stop cold turkey. It’s dangerous for you and your baby.
2. Ask for MAT. Methadone or buprenorphine are the safest options.
3. Start care as early as possible. First trimester is ideal.
4. Expect your baby to be monitored after birth. It’s normal, not a failure.
5. Breastfeeding is usually safe and helpful.
6. Ask for help with mental health, housing, and childcare. You don’t have to do this alone.

Recovery isn’t about perfection. It’s about progress. Every day you stay in treatment, you’re giving your baby a better chance.