Opioids During Pregnancy: Risks, Withdrawal, and Monitoring

When a pregnant person is using opioids-whether prescribed for pain or misused as part of an addiction-the stakes aren’t just high, they’re life-altering. The baby doesn’t just inherit the drug exposure; they inherit the consequences. That’s why managing opioid use during pregnancy isn’t about judgment. It’s about science, safety, and survival.

What Happens When Opioids Cross the Placenta?

Opioids like oxycodone, hydrocodone, heroin, or even prescription painkillers don’t stay in the mother’s bloodstream. They cross the placenta. The baby’s developing brain gets exposed, and over time, it adapts. That adaptation is what leads to Neonatal Opioid Withdrawal Syndrome (NOWS), once called Neonatal Abstinence Syndrome (NAS). About 50 to 80% of babies born to people using opioids during pregnancy will show signs of withdrawal after birth.

Symptoms don’t show up right away. Most appear between 48 and 72 hours after delivery. They include:

• High-pitched crying that won’t calm down
• Shaking or tremors
• Feeding problems-poor latch, vomiting, or refusing to eat
• Loose, watery stools (more than three per hour)
• Fast breathing (over 60 breaths per minute)
• Temperature swings-over 37.2°C
• Excessive sweating or skin mottling

These aren’t just uncomfortable for the baby. They’re dangerous. Without proper monitoring, babies can develop seizures, dehydration, or failure to thrive. That’s why hospitals now follow strict protocols to catch these signs early.

Why Withdrawal Isn’t the Answer

Some people think the best way to protect the baby is to stop opioids cold turkey. That’s a dangerous myth. Medically supervised withdrawal during pregnancy increases the risk of miscarriage by 5 to 8%, preterm labor by 25 to 30%, and fetal distress by nearly double compared to staying on medication-assisted treatment (MAT).

The CDC and the American College of Obstetricians and Gynecologists (ACOG) both say: Do not stop opioids abruptly. The risks to both mother and baby are too high. Relapse rates after withdrawal are 30 to 40% higher. And when someone relapses, they often use more than before-increasing the chance of overdose, infection, or unsafe environments for the baby.

Instead, the standard of care is MAT: medication-assisted treatment. Two drugs are used: methadone and buprenorphine. Both are opioid agonists, meaning they activate the same brain receptors as heroin or painkillers-but in a controlled, stable way. They prevent withdrawal without causing a high. That stability is what keeps the pregnancy on track.

Methadone vs. Buprenorphine: What’s the Difference?

Not all MAT is the same. Methadone and buprenorphine work differently, and each has trade-offs.

Methadone is taken daily as a liquid. It’s been used for decades. It keeps most mothers in treatment-70 to 80% stick with it after six months. But babies born to mothers on methadone tend to have more severe withdrawal. On average, their hospital stays are nearly five days longer than those on buprenorphine. Their Finnegan NAS scores (a tool doctors use to measure severity) average 14.3, compared to 11.8 for buprenorphine-exposed infants.

Buprenorphine is taken as a dissolving tablet or film under the tongue. It’s easier to access and has fewer side effects for the mother. Babies exposed to it have milder withdrawal symptoms and shorter hospital stays-about 12 days on average. But here’s the catch: about 46% of these babies still need medication to manage withdrawal. And in one 2022 study, 92% of buprenorphine-exposed infants showed signs of NOWS.

There’s a third option: naltrexone. It’s not an opioid. It blocks opioids from working. In a small but telling study, infants exposed to naltrexone during pregnancy had zero cases of NOWS. Their hospital stays were 3.2 days shorter on average. And 83% of mothers were able to breastfeed successfully.

But here’s the problem: naltrexone isn’t for everyone. People on naltrexone in that study started prenatal care at 28.4 weeks-nearly nine weeks later than those on buprenorphine. That delay suggests many women weren’t stable enough to start naltrexone early. It’s not a first-line option, but it’s a promising tool for those who can access it in time.

How Babies Are Monitored After Birth

Every baby born to someone using opioids must be watched closely for at least 72 hours. Hospitals use standardized tools like the Finnegan scale or the newer Eat, Sleep, Console method.

The Finnegan scale scores symptoms like tremors, irritability, and feeding issues. A score of 8 or higher usually means medication is needed. But it’s subjective. There are 37 different scoring systems used across U.S. hospitals. That inconsistency makes it hard to compare outcomes or know if one hospital is doing better than another.

The Eat, Sleep, Console approach is changing that. Instead of scoring every cry or twitch, staff ask three simple questions:

1. Can the baby eat?
2. Can the baby sleep for more than an hour at a time?
3. Can the baby be soothed without medication?

Hospitals using this method have seen a 30 to 40% drop in babies needing morphine or methadone for withdrawal. It’s less about numbers and more about the baby’s ability to regulate.

Monitoring happens every 3 to 4 hours in the first 24 hours, then every 4 to 6 hours after that. If symptoms get worse, medication starts. Morphine or methadone are used to wean the baby slowly over days or weeks.

What About Breastfeeding?

Breastfeeding is safe-and encouraged-for most mothers on methadone or buprenorphine. The amount of drug that passes into breast milk is tiny. The American Academy of Pediatrics says the benefits outweigh the risks. In fact, breastfeeding can reduce the severity and duration of withdrawal symptoms.

Mothers on naltrexone can also breastfeed without issue. In the 2022 study, 83% of them did so successfully.

But stigma is real. Many mothers report being told not to breastfeed, even when it’s medically safe. Some nurses assume breastfeeding will worsen withdrawal. That’s not true. If you’re on MAT, ask for a lactation consultant. Don’t let fear stop you from doing what’s best for your baby.

The Bigger Picture: Access, Stigma, and Support

Only 45% of U.S. hospitals have standardized protocols for managing opioid use in pregnancy. In rural areas, that number drops to 28%. Many women don’t get care until late in pregnancy-or not at all.

The 2020 SUPPORT Act required Medicaid to cover MAT for pregnant women. But only 32 states fully comply. That means access depends on where you live.

And then there’s stigma. Over half of mothers in recovery forums report being judged by doctors, nurses, or social workers. One mother on Reddit said, “I felt like a criminal for being pregnant while on medication.” That fear keeps people from seeking help.

The best outcomes happen when care is coordinated. That means an OB-GYN, an addiction specialist, a pediatrician, a social worker, and a mental health provider all working together. Many pregnant women with OUD also struggle with depression-over 30% screen positive for moderate to severe depression. Without mental health support, recovery is harder.

What’s New in 2025?

The FDA approved Brixadi in 2023-a once-weekly injection of buprenorphine designed for pregnancy. Early results show 89% of women stayed in treatment at 24 weeks, compared to 76% on daily pills. That’s huge. Missing a daily dose can mean withdrawal. A weekly shot removes that risk.

The American Academy of Pediatrics now recommends at least two hours of non-medication care-skin-to-skin contact, swaddling, quiet rooms-before giving any drugs for withdrawal. And the NIH’s HEALing Communities Study is testing full integration of care in 67 areas. Early data shows a 22% drop in NAS severity when housing, food, mental health, and MAT are all addressed together.

Because recovery isn’t just about drugs. It’s about safety. Stability. Support.

What You Can Do

If you’re pregnant and using opioids:

• Don’t stop on your own. Talk to a provider who specializes in addiction and pregnancy.
• Ask about MAT-methadone, buprenorphine, or naltrexone if you’re eligible.
• Find a hospital that uses the Eat, Sleep, Console method.
• Request a lactation consultant if you plan to breastfeed.
• Ask for mental health screening. Depression and trauma are common-and treatable.

If you’re a provider:

• Screen every pregnant patient for substance use-not just at the first visit, but throughout.
• Know your hospital’s protocol. If you don’t have one, help create one.
• Treat addiction like any other chronic condition. No shame. No judgment.

Frequently Asked Questions