A research letter published in JAMA Network Open found that higher doses of methadone or buprenorphine in pregnant patients did not lead to more severe withdrawal in newborns. The study, which included 92 pregnancies and 94 newborns, analyzed umbilical cord tissue for drug levels and compared them to neonatal opioid withdrawal syndrome (NOWS) in the babies.
The researchers found that 43.6% of the babies had severe withdrawal, but the mothers’ doses of methadone or buprenorphine did not correlate with the severity of withdrawal. The median methadone dose was 127.5 milligrams for mothers whose babies had severe withdrawal and 120 milligrams for those whose babies did not, a difference that was not statistically significant.
Study Findings
Dr. Courtney Townsel, the study’s lead author, noted that reducing the dose does not give the baby an easier withdrawal. It only puts the mother at risk. The researchers emphasized that doses should be based on the mother’s clinical stability to reduce the risk of relapse and overdose.
The type of medication used was a more significant factor in severe withdrawal than the dose. Methadone-exposed babies were more likely to experience severe withdrawal (55.6%) compared to buprenorphine-exposed babies (27.5%). After adjusting for gestational age, maternal smoking, and study site, methadone exposure was associated with about 3.4 times higher odds of severe withdrawal.
Babies exposed to methadone were also more likely to be treated with medication for withdrawal (33.3% compared to 10%) and stayed in the hospital for a median of eight days compared to five days for buprenorphine-exposed babies. However, the authors cautioned that this should not be taken as a reason to switch medications mid-pregnancy, as the choice between methadone and buprenorphine often reflects a patient’s history and clinical stability.
The study’s findings align with existing federal guidance, which recommends methadone or buprenorphine as the preferred therapy for opioid use disorder in pregnant patients.
Implications for Pregnant Patients
The study’s results are particularly relevant for pregnant patients already in treatment and their healthcare providers. Opioid use disorder is a leading cause of death associated with pregnancy and the postpartum period, with mortality rates rising over 80% between 2017 and 2020, according to the American Medical Association.
Pregnant patients should not lower, stop, or switch medication on their own, but rather discuss any concerns with their clinician. A prenatal visit is an opportunity to ask about the current dose, how the baby will be monitored after birth, and whether breastfeeding is an option. Dr. Irina Burd, co-author and chair of the Department of Obstetrics, Gynecology and Reproductive Sciences at the University of Maryland School of Medicine, emphasized that clinicians should focus on maintaining effective treatment for the mother rather than lowering medication doses in an attempt to prevent neonatal withdrawal.
State Medicaid programs are required to cover medication treatment for opioid use disorder, and federally funded treatment programs must give pregnant women preference in admission. Resources such as FindTreatment.gov and the SAMHSA National Helpline (1-800-662-4357) can connect people to local care.
The researchers analyzed umbilical cord tissue from the 94 newborns, which reflects the baby’s drug exposure over the last trimester. They found that higher methadone doses produced higher cord drug levels, but these levels were similar in babies with and without severe withdrawal.
Treatment and Support
The study was funded by the Society for Maternal-Fetal Medicine Foundation, the American Association of Obstetricians and Gynecologists, and the Robert Wood Johnson Foundation. The authors disclosed nonfinancial support and equity in a patent, but these did not affect the study.
Withdrawal in a newborn is treatable, and hospitals monitor exposed babies for several days. Many hospitals use the Eat, Sleep, Console approach, which encourages parents to stay with the baby, hold skin-to-skin, and feed on demand. Anyone who sees signs of an overdose should give naloxone and call 911.
