Opioid Use Disorder (OUD) in pregnancy is an increasingly urgent public health issue. In the U.S., the prevalence of OUD in pregnancy has doubled in the past decade.1
Overdose related to opioid and other substance use disorders (OUD/SUD) is the leading cause of pregnancy-associated mortality, accounting for nearly a third of pregnancy-associated deaths in Michigan.² Ongoing substance use in pregnancy is associated with adverse outcomes for both the birthing person and the baby. However, many of these outcomes can be mitigated through comprehensive, integrated care.³ Addressing the crisis requires a comprehensive approach that includes preventions, improved access to evidence-based treatment, harm reduction strategies, and addressing the underlying factors contributing to substance use.
Learn More About Stigma Reduction
Harm reduction shifts the conversation from getting people to do the “right thing” to getting people to come back safely.Learn More About Harm Reduction
This is a comprehensive harm reduction toolkit for supporting individuals who use substances during pregnancy, offering practical resources, guidance, and evidence-based strategies to promote health and dignity for pregnant people and their families.
This site shows where to get services for substance use disorder in Michigan.
This page offers a comparative overview of various social needs screening tools used in healthcare settings, enabling providers to select and implement the most appropriate instruments for identifying patients’ social and economic challenges.
Birthing people with OUD/SUD experience high rates of bias and stigma in medical care settings. Fear is the number one reason why this population doesn’t seek care.⁴,⁵ The initial visit is crucial for relationship building and getting patients to want to come back. Treating patients without judgement and celebrating their efforts to start care is crucial in creating a stigma-free environment.
Key Points:
The following chart provides a side-by-side overview of medications for opioid use disorder—methadone, buprenorphine, and naltrexone—highlighting key differences in medication type, available forms, associated risks, and important considerations for pregnancy and birth.
| Methadone | Buprenorphine | Naltrexone | |
|---|---|---|---|
| Medication | Agonist | Partial agonist (displaces opioids) | Antagonist (blocks the effects of opioids) |
| Forms | Tablet, liquid | Strip, film, tablet, injectables Combined buprenorphine and naloxone is preferred | Tablet, injectable |
| Risks | QT prolongation, drug interactions, overdose | Decreased overdose risk, precipitated withdrawal, dental caries | Precipitated withdrawal |
| Labor and Delivery Considerations | Continue; consider split dosing | Continue; consider split dosing | Discontinue 72 hours before labor/birth admission |
| Pregnancy Consideration | NOWS rates 60-80% | NOWS rates 20-40% | Less pregnancy specific data. NOWS rates 0% in one study |
Medication management during pregnancy requires a flexible, patient-centered approach that supports individuals by accounting for physiologic changes, addressing cravings or withdrawal, prioritizing harm reduction, and engaging patients in shared decision-making to promote safety and stability.
Routine urine drug screening is controversial, and ACOG advises it should only occur with patient consent and that a positive result should not impact care, public program coverage, or decisions about family separation.
Learn more about the purpose of the SBIRT program Screening, Brief Intervention, and Referral to Treatment through the lens of the Substance Abuse and Mental Health Services Administration.
Providing comprehensive, person-centered prenatal care is essential for supporting pregnant patients who use substances or are in recovery. This includes proactively managing common pregnancy discomforts, completing recommended third trimester evaluations, and preparing for individualized peripartum pain management. Because unmanaged pain can increase the risk of return to use, prenatal care should emphasize early planning, shared decision making, and access to both pharmacologic and non-pharmacologic options. Through thoughtful counseling, development of a personalized birth and postpartum plan, and education about newborn care—including Neonatal Opioid Withdrawal Syndrome—clinicians can help ensure safer, more informed, and more empowered experiences throughout pregnancy, labor, and the postpartum period.
Key Points:
Develop a comprehensive birth plan that includes clear strategies for managing pain by first reviewing expectations for pain management during labor and the postpartum period.
This planning should also incorporate a discussion of birth and postpartum preferences and available options, ensuring the plan reflects the patient’s values and goals. As part of this process, consider who will provide support during labor and after delivery, including trusted support people and, when available, peer recovery coaches or doulas. It is also important to review urine drug screening (UDS) considerations and labor and delivery policies in advance so expectations are clear and transparent.
Consider these non-pharmacologic and pharmacologic approaches to managing pain during and after birth.
| Non-Pharmacologic | Pharmacologic | |
|---|---|---|
| Labor, Delivery, Birth | - Movement and positions - Labor support devices (peanut ball, labor chair) - Heat and/or ice - Mindfulness - Labor support people (e.g., doula, support person) - Hydrotherapy | - Nitrous oxide - IV opioid (should discuss patient’s comfort) - Epidural |
| Postpartum | - Heat and/or ice - Abdominal binder - Mindfulness - Support person (e.g., doula, support person) - Cognitive Behavioral Therapy | - Non-opioid medications (ibuprofen and acetaminophen) - Topical analgesia (lidocaine patches/spray) - Prolonged epidural - Regional pain blocks - When necessary and with consent, opioids can be prescribed |
Ongoing prenatal care should include compassionate, trauma-informed screening and mental health support, recognizing that substance use, mental health conditions, and past trauma are often interconnected and require thoughtful, patient-centered approaches throughout pregnancy. Receiving information from a patient is a privilege. If a patient is not comfortable discussing substance use, respect their readiness and offer to revisit the questions at a later time.
Verbal drug screening includes a series of standardized questions (e.g. NIDA quick screen) asked to all patients about substance use. Universal screening reduces inequities in urine drug testing. Begin by explaining the rationale: substance use can impact health and wellbeing, and screening enables you to connect patients with appropriate support and resources. Normalize the screening process by integrating screenings into routine workflows and informing patients these questions are asked to everyone. Discuss implications of a positive screen with patients before asking the questions. These strategies can help build trust and transparency.
Urine drug testing is a method used to detect or confirm recent substance use. Always obtain informed consent before testing. Clearly explain the purpose of the test and discuss the possible implications of a positive result as part of the consent process. When used properly, drug testing can be a helpful tool to confirm engagement with MOUD and to support patients in their recovery journey. Providers may consider a written informed consent process.
If a patient screens positive, provide Brief Intervention and Referral to Treatments (SBIRT).
Screening: Identify Substance Use with a validated questionnaire
Brief Intervention:
Referral to Treatment: Ask permission to connect patient with available resources
Supporting mental health during pregnancy requires a comprehensive, team-based approach that combines routine screening, trauma-informed and person-centered care, collaborative partnerships, and evidence-based interventions to promote safety, stability, and overall wellbeing.
More than 80% of patients who have a substance use disorder have a lifetime history of trauma and >80% have concurrent mental health diagnoses. To properly manage OUD/SUD, it is critical to address and treat the co-occurring mental health conditions. There are many evidence-based strategies for managing and treating mental health.
Trauma is common
Trauma changes trust and world view
Trauma has long term impacts on physical and mental health
The impact of trauma can have multigenerational effects
Pain management can be more complex for birthing people with OUD/SUD. When discussing postpartum pain management with patients, it’s essential to set realistic expectations and emphasize individualized, safe care. Reassure patients that effective pain management strategies are available and discuss the role of insufficient pain management in return to substance use. Discuss that some discomfort is expected, and that they should reach out with any concerns.
Key Points:
Ideally, pain management conversations begin BEFORE the labor and delivery admission, and include discussions of expected pain, options for pain management, risks specific to individuals with OUD, and an understanding of patients preferences for pain management. An interprofessional approach including the obstetric, anesthesia, addiction, and psychiatry teams where available is ideal.
Postpartum pain plans should start with neuraxial and regional anesthesia as appropriate during labor and/or delivery. Postpartum, clinicians should start with optimizing non-opioid options, including scheduled acetaminophen and NSAIDS, along with non-pharmacologic approaches.
If pain is not managed with these approaches, clinicians can discuss opioid medications with the patient. It is important to emphasize that insufficiently managed pain is a risk factor for return to substance use. Patients receiving MOUD may require higher doses of opioid medication or opioids with higher affinity for the opioid receptor (e.g., hydromorphone). If patients require an opioid prescription at discharge, it is important to discuss safe medication storage and naloxone. Consider short interval follow-up through in-person or virtual visits (within 3-5 days) to adjust pain management plans.
It is crucial to create a safe space for patients to share their recovery goals and any concerns about medications. Collaborate with the patient to develop a pain management plan that aligns with their needs and supports their recovery, adjusting the approach as needed. Encourage patients to communicate if their pain is not well-controlled or if issues arise so that the care plan can be tailored appropriately.
