Purpose of This Guideline

Date of current publication: July 16, 2021 Lead authors: Kelly S. Ramsey, MD, MPH, MA, FACP Writing group: Sharon Stancliff, MD; Lyn C. Stevens, MS, NP, ACRN; Christopher J. Hoffmann, MD, MPH; Charles J. Gonzalez, MD Committee: Substance Use Guidelines Committee Date of original publication: July 16, 2021

Goals: This guideline on the treatment of substance use disorders (SUDs) in pregnant adults (≥18 years old) was developed by the New York State (NYS) Department of Health (DOH) AIDS Institute (AI) to establish a New York State standard of care. The goal of this guideline is to ensure that healthcare providers in New York State are aware of and able to provide appropriate options for SUD treatment during pregnancy and to:

• Inform clinicians of available treatment options for SUDs to expand access to SUD treatment for pregnant individuals.
• Provide evidence-based recommendations to guide the management of substance use and SUDs during pregnancy.
• Promote a harm reduction approach to SUD treatment in pregnancy by providing practical strategies for reducing the negative consequences of drug and alcohol use during pregnancy.
• Increase awareness among healthcare providers about the stigma associated with drug and alcohol use during pregnancy.

Use of this guideline: This guideline is intended for clinicians with patients who have SUDs during pregnancy. SUD treatment during pregnancy can be managed in various inpatient and outpatient settings. Communication and coordination among healthcare providers are essential.

Many aspects of SUD treatment are the same for pregnant and nonpregnant patients. The recommendations in this guideline focus on aspects of SUD treatment that differ for pregnant individuals; where appropriate, clinicians are referred to the following NYSDOH AI guidelines for more information:

• Treatment of Opioid Use Disorder
• Treatment of Alcohol Use Disorder
• Substance Use Harm Reduction in Medical Care

The recommendations presented here address the treatment of SUD in pregnant patients; they do not address the management of pregnancy itself.

Prevalence and Risks of Substance Use Disorder During Pregnancy

Goals of Substance Use Disorder Treatment During Pregnancy

For recommendations on substance use screening during pregnancy, see the NYSDOH AI guideline Substance Use Screening and Risk Assessment in Adults.

Pregnancy is not a contraindication for substance use disorder (SUD) treatment. Treatment can be managed in various settings by perinatal, primary care, or SUD specialty providers. SUD treatment and other aspects of care for pregnant patients should be coordinated among healthcare providers.

SUD treatment goals during pregnancy can include:

• Abstaining from or reducing substance use
• Preventing adverse effects of substance use or withdrawal for the pregnant individual and fetus
• Staying in care, which can also facilitate prevention, diagnosis, and treatment of other conditions
• Reducing high-risk behaviors, such as injection drug use and use or reuse of unsterile equipment and sharing injection equipment, and reducing related complications, such as infection and overdose
• Improving the quality of life and other social conditions, such as employment, stable housing, and risk of incarceration

Barriers to care: Engagement in substance use care is associated with better maternal and neonatal outcomes [Minozzi, et al. 2020; Chamberlain, et al. 2017; Binder and Vavrinková 2008; O'Connor and Whaley 2007]. However, pregnant individuals who use substances can face substantial obstacles to healthcare access, ranging from lack of transportation to fear of legal consequences, which may delay care until late in the pregnancy or the point of delivery [Stone 2015]. Pregnant Black women are more likely to be tested for drug use during pregnancy and referred to child protective services than their non-Black counterparts despite equivalent rates of positive drug tests between the 2 groups [Kunins, et al. 2007]. The influence of implicit care provider bias and institutional racism in the healthcare system on these different testing and reporting rates cannot be ignored. Most states have laws requiring the reporting of prenatal drug exposure [Guttmacher Institute 2022]. Fear of being reported, legal action, and child services involvement may lead to the avoidance of prenatal or substance use treatment and possible negative health consequences for the parent and infant [Angelotta, et al. 2016; House, et al. 2016; Stone 2015].

Opioid Use Disorder Treatment During Pregnancy

Note: Many aspects of opioid use disorder (OUD) treatment in pregnant individuals are similar to treatment in nonpregnant individuals, including the preferred medications. The recommendations below focus on differences in treatment during pregnancy; consult the NYSDOH AI guidelines Treatment of Opioid Use Disorder and Substance Use Harm Reduction in Medical Care for additional recommendations.

Avoid opioid withdrawal: Abrupt discontinuation of opioids, including BUP or methadone, should be avoided during pregnancy to prevent or minimize withdrawal symptoms. Consultation with an experienced substance use treatment provider may be appropriate. Inconsistent opioid levels during pregnancy may precipitate withdrawal in the fetus, which can harm placental function and can increase the risks of NOWS, stunted growth, preterm labor, fetal convulsions, and fetal death [Hudak and Tan 2012; Kaltenbach, et al. 1998].

Maternal and fetal risks and benefits of opioid use and treatment: Treatment with BUP or methadone is the standard of care for OUD in pregnant patients (see SAMHSA Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants). Treatment with BUP or methadone reduced use of opioids and decreased risk of preterm delivery, low infant birth weight, and transmission of HIV to the neonate [Minozzi, et al. 2020; ACOG(a) 2017; Saia, et al. 2016; Wiegand, et al. 2015; Gawronski, et al. 2014; Mozurkewich and Rayburn 2014; Lund, et al. 2013; Wong, et al. 2011; Jones, et al. 2010; Binder and Vavrinková 2008]. Table 1, below, summarizes the risks and benefits of BUP and methadone.

Although infants exposed to BUP or methadone can experience NOWS, the severity of symptoms is reduced when the mother is taking medication for OUD treatment [Brogly, et al. 2014; Fajemirokun-Odudeyi, et al. 2006]. The risk of NOWS does not differ based on treatment with BUP or methadone, but studies indicate that infants exposed to BUP/NLX in utero are less likely to require treatment for NOWS than those exposed to other opioid agonist medications, including BUP, methadone, or long-acting opioids [Link, et al. 2020]. In a study comparing BUP and methadone treatment during pregnancy, neonates exposed to BUP had significantly less severe NOWS, a shorter duration of treatment for NOWs, and shorter hospital stay than those exposed to methadone [Jones, et al. 2010].

A long-term study of infants exposed to BUP or methadone in utero reported healthy growth and cognitive and psychological development at 36 months of age for both groups [Kaltenbach, et al. 2018]. In addition, a recent meta-analysis found no significant differences in cognitive development scores in children up to 5 years old with and without prenatal exposure to methadone or BUP [Nelson, et al. 2020].

Buprenorphine monoformulation or buprenorphine/naloxone: A recent systematic review of 5 studies with 6 study groups found no significant differences in adverse maternal and neonatal outcomes when comparing BUP/naloxone (NLX) or methadone treatment in pregnancy. Outcomes included admission to the neonatal intensive care unit, full-term delivery, vaginal delivery, neonatal length of stay, gestational age at delivery, neonatal length, birthweight, and neonatal head circumference [Link, et al. 2020; Mullins, et al. 2020; Nechanská, et al. 2018; Jumah, et al. 2016; Wiegand, et al. 2015; Gawronski, et al. 2014]. Pregnant patients who are initiating or continuing BUP maintenance can choose either the monoformulation or BUP/NLX.

Naltrexone: The NYSDOH AI guideline Treatment of Opioid Use Disorder > Treatment Considerations recommends naltrexone as an alternative to be offered if patients cannot take BUP or methadone or prefer naltrexone.

If a pregnant individual is currently using opioids, initiation of naltrexone is not recommended because withdrawal from opioids is required [Towers, et al. 2020; ACOG(a) 2017; Jones, et al. 2013; FDA 2010; Hulse, et al. 2004]. If a patient taking naltrexone becomes pregnant, clinicians should inform the patient of the risks and benefits of naltrexone and the preferred pharmacologic treatment options to support informed and shared decision-making about treatment (see Table 2, below). If the patient opts to discontinue naltrexone and initiate methadone or BUP, clinicians should educate the patient about the risk of NOWS.

Initiating buprenorphine: In pregnant patients, BUP should be initiated when a patient is experiencing mild opioid withdrawal symptoms (see the Clinical Opiate Withdrawal Scale and Subjective Opiate Withdrawal Scale) [Wesson and Ling 2003; Handelsman, et al. 1987]. For nonpregnant patients, clinicians are advised to initiate treatment when the patient is experiencing moderate withdrawal symptoms. However, if a pregnant individual is experiencing physiological withdrawal, it affects the fetus, too, so medication is initiated earlier in withdrawal to avoid the increased risk to the fetus.

One emerging strategy for BUP/NLX induction is “microdosing,” which does not require opioid withdrawal [Randhawa, et al. 2020; Klaire, et al. 2019; Hämmig, et al. 2016]. A small initial dose (e.g., 0.5 mg/0.125 mg) is followed by small incremental increases over 7 to 10 days; patients can continue to use other opioids until the therapeutic level of BUP/NLX is reached. Case reports on nonpregnant adults indicate that BUP/NLX microdosing is well tolerated and may reduce opioid cravings and withdrawal symptoms during induction [Klaire, et al. 2019; Hämmig, et al. 2016]. Microdosing is an emerging strategy for BUP/NLX induction, and studies are needed to guide clinical care. To date, BUP/NLX microdosing has not been studied in pregnant individuals. Because of the lack of data, this committee does not take a position on microdosing during BUP/NLX induction in pregnant patients.

Although there is little published evidence, clinical experience supports a cautious approach to BUP induction in pregnant individuals, with slow titration to the optimal dose for a pregnant patient. For example, clinicians can advise patients to take an initial dose of BUP 2 mg, followed 30 to 60 minutes later by an additional 2 mg [Jones, et al. 2008]. If the patient experiences any worsening of opioid withdrawal symptoms within 30 to 60 minutes after a dose of BUP, the interval between doses can be decreased. The pattern of increasing BUP in 2 mg increments and waiting 30 to 60 minutes before the next increase continues until the dose is sufficient to control opioid cravings and prevent withdrawal.

Continuing opioid use disorder treatment through pregnancy, labor, delivery, and postpartum: Patients with OUD who initiate BUP or methadone during pregnancy or who become pregnant while taking either medication should continue treatment with the same medication throughout the intra- and postpartum periods [Meyer, et al. 2015; Lund, et al. 2013; Jones, et al. 2010].

If treatment goals are not being met with BUP treatment during the pregnancy, clinicians should refer the patient to an OTP for methadone treatment if available [ACOG(a) 2017]. However, during pregnancy, a switch from methadone to BUP is not recommended because the transition could cause precipitated opioid withdrawal symptoms and may require inpatient care and monitoring to decrease the risk of miscarriage or premature delivery. If a patient requests a change from methadone to BUP, clinicians are advised to consult with an expert in OUD treatment during pregnancy.

Monitor for dose increase later in pregnancy: An increased dose of BUP or methadone may be required late in the second and third trimesters because of increased blood volume and metabolism later in pregnancy [Bastian, et al. 2017; Albright, et al. 2011; Cleary, et al. 2010]. Patients may opt to split their BUP dose during the day if it suits their comfort level. Clinicians should assess withdrawal symptoms and opioid cravings at every visit. If a pregnant patient is experiencing any opioid withdrawal symptoms or opioid cravings, the dose of medication should be increased, typically in increments of 5 mg to 10 mg per day for methadone (every 3 to 5 days as needed) and 2 mg to 4 mg per day for BUP. The medication dose should be reassessed at each visit. Patient education is essential to ensure that the patient understands that increasing the dose of either BUP or methadone will not increase the risk of NOWS [Wong, et al. 2018; Cleary, et al. 2010; Jones, et al. 2010].

If a pregnant patient taking methadone has withdrawal symptoms or cravings that are not relieved by a dose increase, the OTP should perform testing for the patient’s serum peak and trough levels of methadone. If the peak-to-trough level ratio is higher than 3:1, the methadone dosage should be divided and administered twice daily, ideally every 12 hours.

Pain management: At a minimum, the maintenance OUD treatment dose of methadone or BUP is maintained [ASAM(b) 2020]. Nonopioid medications are the first-line option. The addition of a short-acting full-agonist opioid can be considered to manage moderate to severe acute pain. When adding a full-agonist opioid analgesic, patients will likely need a higher dose than opioid-naive patients to achieve adequate analgesia [ASAM(b) 2020].

Breastfeeding: Breastfeeding is safe when a patient takes methadone, BUP, or naltrexone [LactMed(b) 2022; LactMed(e) 2022; LactMed(a) 2021]. In addition, breastfeeding has been shown to decrease the risk of NOWS and, when NOWS does occur, decrease the need for pharmacologic treatment [Reece-Stremtan and Marinelli 2015; Welle-Strand, et al. 2013; McQueen, et al. 2011; Jansson, et al. 2008]. This benefit is likely due to the skin-to-skin contact inherent in breastfeeding rather than the minuscule amount of BUP or methadone in breast milk. The only contraindication to breastfeeding is HIV infection. Hepatitis C virus infection is not a contraindication to breastfeeding as long as the skin of the nipple is intact.

Postpartum considerations: Following birth, a patient who is taking medications to treat OUD will require continued treatment and support. The postpartum period can be stressful for new parents, particularly if they lack social support and have comorbidities, such as mental health diagnoses or chronic medical conditions; during this period, individuals who use opioids are at increased risk for recurrence of use and unintentional overdoses [Schiff, et al. 2018]. One study found that individuals who gave birth to infants with NOWS had a significantly higher incidence of major depression, postpartum depression, and anxiety in the 12 months postpartum than matched controls [Corr, et al. 2020]. A population-based study in Massachusetts found that overdose events decreased with progression through the pregnancy and were lowest in the third trimester (3/100,000 person-days); the highest risk of overdose occurred 7 to 12 months after delivery (12.3/100,000 person-days) [Schiff, et al. 2018].

In the postpartum period, the mother should continue taking BUP or methadone for as long as a benefit is derived. If the patient’s dose of BUP or methadone was increased during pregnancy, clinicians should not decrease the dose to the prepregnancy level immediately postpartum; dose decreases should be individualized.

Neonatal Opioid Withdrawal Syndrome

Clinicians should inform pregnant patients who are taking opioids, buprenorphine (BUP), or methadone, that NOWS is an expected and treatable neonatal outcome. Patient education about NOWS may reduce stress after delivery.

Risk of neonatal opioid withdrawal syndrome: A fetus that is exposed to opioids, methadone, or BUP during pregnancy is at risk of developing NOWS [ACOG(a) 2017; Kraft, et al. 2016; McQueen and Murphy-Oikonen 2016; Saia, et al. 2016; Gawronski, et al. 2014; Hall, et al. 2014; Kocherlakota 2014; Wong, et al. 2011; Jones, et al. 2010; Bakstad, et al. 2009].

Harm reduction: Strategies to reduce the severity of NOWS include treatment with BUP or methadone and preventing opioid withdrawal in pregnant patients who use opioids [Brogly, et al. 2014; Fajemirokun-Odudeyi, et al. 2006]. There is no association between BUP or methadone dose and the likelihood of NOWS; therefore, dose reductions to avoid NOWS are not advised [Kaltenbach, et al. 1998]. Reducing the dose of BUP or methadone may increase illicit drug use and increase the risk to the fetus.

Symptoms: Signs of opioid withdrawal generally occur within the first 48 hours of life for neonates exposed to BUP in utero and within 5 days for those exposed to methadone. Symptoms include tremors, hypertonicity, irritability, vomiting, and respiratory distress, and the number, severity, and duration of symptoms vary in individual neonates [Zelson, et al. 1973]. Multiple factors affect the expression of symptoms: neonatal gestational age, sex, and genetics; maternal substance use factors, exposure to medications (selective serotonin reuptake inhibitors, benzodiazepines, gabapentinoids), smoking, and metabolism [Kraft, et al. 2016]. Diagnosis of NOWS is based on maternal history and neonatal clinical features, with or without biological testing [Anbalagan and Mendez 2022].

Tools such as the Finnegan Neonatal Abstinence Scoring System [Finnegan and Kaltenbach 1997] and the MOTHERS score [Jones, et al. 2010] are used to assess central nervous system, metabolic, vasomotor, respiratory, and gastrointestinal symptoms. The score is used to guide treatment decisions, including the initiation of pharmacologic treatment. A diagnosis of NOWS can require individually tailored supportive care strategies because presenting symptoms can vary [Wiles, et al. 2014; Velez and Jansson 2008]

Treatment: The treatment goals are to minimize the severity and duration of withdrawal symptoms in the infant and reduce the length of hospital stay and the need for adjunctive therapies. Current practice encourages nonpharmacologic management of NOWS and infant-family contact [Ryan, et al. 2019; Grossman, et al. 2018].

Because many NOWS symptoms are associated with infant overstimulation, nonpharmacologic care focuses on controlling environmental factors to maximize infant comfort. Methods include swaddling, quiet and dimly lit rooms, skin-to-skin contact, breastfeeding, and infant positioning [Ryan, et al. 2019]. Several studies have found that rooming-in, or keeping an infant with the parent instead of a neonatal intensive care unit, is associated with decreased need for NOWS pharmacologic treatment and reduced length of hospital stay [Lembeck, et al. 2019; Holmes, et al. 2016; Saiki, et al. 2010; Abrahams, et al. 2007]. In the “eating/sleeping/consoling” (ESC) approach, if infants can be consoled in less than 10 minutes, eat an ounce or more of formula or breastfeed well, and sleep for an hour or longer at a time with nonpharmacologic strategies, no medication is indicated for the treatment of NOWS [Grossman, et al. 2018].

Mild cases of NOWS (Finnegan Score <8) can often be managed with nonpharmacologic treatment; more severe cases may require adjunctive medication [Ryan, et al. 2019]. Medication, generally morphine and, less commonly, methadone, is the first-line pharmacologic treatment for NOWS [Kocherlakota 2014; Hudak and Tan 2012; Jansson and Velez 2012; Osborn(a), et al. 2010; Osborn(b), et al. 2010].

Buprenorphine is safe for the treatment of NOWS, and sublingual dosing has been demonstrated to be feasible in the neonatal population [Kraft, et al. 2008]. BUP has been shown to have an efficacy advantage over standard opioid therapy for NOWS in controlled clinical trials and treatment settings [Kraft 2018]; however, its use is not yet widespread.

There is significant variability in treatment approaches to NOWS, and an optimal protocol has not been established [Kraft, et al. 2016; Tolia, et al. 2015; Patrick, et al. 2014; O'Grady, et al. 2009; Sarkar and Donn 2006]. Despite significant effort in the medical community to find the most effective medication and dosing regimen for treatment of NOWS, the use of a standardized institutional protocol based on best practices is more effective than a specific medication (morphine or methadone) in reducing the total length of hospital stay and duration of pharmacologic treatment [Kraft, et al. 2016]. The most effective treatment approaches employ a systematic, multidisciplinary, and multimodal approach.

Alcohol Use and Alcohol Use Disorder Treatment During Pregnancy

Note: This section of the guideline addresses alcohol use in general, rather than alcohol use disorder (AUD), because the risk of harm to the fetus is greater with nondependent alcohol use than with nondependent use of other substances. Some aspects of treatment for pregnant individuals with AUD are similar to those for nonpregnant individuals.

The recommendations below focus on differences in treatment during pregnancy; consult the NYSDOH AI guidelines Treatment of Alcohol Use Disorder and Substance Use Harm Reduction in Medical Care for additional recommendations.

Alcohol withdrawal: Pregnancy is considered a relative indication for inpatient management of alcohol withdrawal and may be indicated for any pregnant patient who requires symptom management. For pregnant patients with a score of 10 or higher on the CIWA-Ar scale or at risk for moderate, severe, or complicated alcohol withdrawal, a referral for inpatient withdrawal management is recommended [ASAM(a) 2020; VA/DoD 2015]. Clinicians should consult with an OB/GYN during withdrawal management [ASAM(a) 2020].

Symptoms of alcohol withdrawal syndrome include autonomic hyperactivity (sweating, fast pulse); increased hand tremors; insomnia; nausea; vomiting; transient hallucinations or perceptual disturbances of the auditory, visual, or tactile type; psychomotor agitation; anxiety; and generalized seizures [Kattimani and Bharadwaj 2013]. Physiologic and psychological stress during pregnancy can adversely affect the pregnant individual and the fetus and result in preterm birth and low birth weight [DeVido, et al. 2015; Enlow, et al. 2009; Hobel, et al. 2008].

Benzodiazepines are commonly used in treating alcohol withdrawal in nonpregnant adults, but data on the safety of benzodiazepines during pregnancy are unclear [DeVido, et al. 2015]. Fetal exposure to benzodiazepines in the first trimester has not been associated with an increased risk of congenital disabilities in limited studies [Bellantuono, et al. 2013]. The World Health Organization and the American Society of Addiction Medicine recommend short-term, limited use of benzodiazepines in pregnant patients who develop alcohol withdrawal and note that the risk of fetal adverse events has to be balanced with the potential harm of complications of severe alcohol withdrawal [ASAM(a) 2020; WHO 2014].

Encourage abstinence or minimal alcohol use: Clinicians should encourage pregnant individuals who use alcohol or have AUD to abstain from or minimize use during pregnancy to decrease the risk of fetal alcohol spectrum disorder (FASD) [Reece-Stremtan and Marinelli 2015; WHO 2014]. Expert consultation or inpatient management of alcohol withdrawal may be needed with patients who are physically dependent on alcohol (see discussion of alcohol withdrawal, above). During pregnancy, heavy alcohol use may lead to various congenital disabilities and alterations in neonatal growth and development [Lees, et al. 2020; Miller 2018]. FASD, which is characterized by congenital abnormalities associated with exposure to alcohol in utero, may cause mild or subtle problems, such as a slight learning disability or physical abnormality, or it may cause more severe problems, such as central nervous system dysfunction, low IQ, microcephaly, delayed growth, and facial abnormalities [Miller 2018].

There is no known safe amount of alcohol use during pregnancy, and there is clear evidence that binge drinking and heavy drinking during pregnancy are associated with adverse fetal effects [Carson, et al. 2017; Flak, et al. 2014; O'Leary and Bower 2012]. Because of the linear dose-response of alcohol on the fetus and the potentially serious and irreversible consequences in the fetus and neonate of in utero exposure, abstaining from or minimizing use is recommended [Chang 2022; May, et al. 2016].

Behavioral treatment: Clinicians should provide or refer pregnant patients who use alcohol for counseling or other psychosocial treatment. A meta-analysis of alcohol screening and brief intervention studies in pregnant patients found that abstinence during pregnancy was consistently higher in the intervention groups (counseling on alcohol use) than the control groups (odds ratio, 2.26; 95% CI, 1.43 to 3.56; 5 studies [n = 796]) after 6 to 12 months [O’Connor, et al. 2018]. Among trials reporting abstinence before delivery, abstinence ranged from 72% to 90% among intervention participants and 55% to 74% among control participants [O’Connor, et al. 2018].

Referral options may include intensive outpatient substance use treatment, mental health treatment, peer support groups (e.g., 12-step, SMART Recovery), electronic apps (e.g., SMART Recovery, In the Rooms), public health, and other community-based recovery coaching, and other available psychosocial interventions. Cognitive-behavioral therapy, motivational interviewing, and contingency management may also help a pregnant patient minimize substance use [WHO 2014]. There is wide variability in the efficacy of these interventions, and recommendations and referrals should be tailored to the individual patient’s needs and preferences.

Harm reduction counseling: Pregnant patients who cannot abstain from alcohol use may be able to decrease use or address other treatment goals. Harm reduction approaches during pregnancy have been shown to decrease alcohol use, reduce healthcare costs, improve engagement and retention in prenatal services and substance use treatment, and improve health outcomes for parents and their children [Racine, et al. 2009; Poole and Greaves 2007]. Clinicians should discuss and encourage harm reduction strategies.

Focusing health messages on abstinence and improving fetal health, although pertinent given the low threshold at which fetal harm can occur, can fail to consider a patient’s social context and address the root causes of alcohol use during pregnancy [O’Leary and Bower 2012]. Studies have shown that trauma, interpersonal violence, and structural inequities may impact alcohol use in pregnancy [Varcoe, et al. 2014; Poole and Greaves 2007]. Patient counseling recommending abstinence can be presented in a rational, nonjudgmental manner, with the treatment goal being to reduce harm to the pregnant individual and the fetus [O’Leary and Bower 2012].

An abstinence-based approach can also perpetuate the social stigmatization of those who use alcohol and inadvertently discourage engagement in care, which contributes to long-term harm to both parents and children. Individuals who use alcohol during pregnancy may avoid accessing prenatal and other medical and social care for fear of judgment or punitive measures, such as child welfare authorities removing their child [Varcoe, et al. 2014; Poole and Greaves 2007].

Pharmacologic treatment: Acamprosate and naltrexone are the preferred agents for pharmacologic treatment of AUD in nonpregnant individuals. However, few data are available from well-controlled studies of acamprosate or naltrexone in pregnant individuals, and the potential carcinogenic, mutagenic, or fertility effects in humans are unknown. In a small study among pregnant individuals treated with naltrexone, outcomes for neonates exposed to naltrexone in utero did not appear to differ from other neonates [Hulse, et al. 2004]. Gabapentin may be considered, but caution should be taken with its use during the third trimester [Patorno, et al. 2020]. Treatment with disulfiram is not advised during pregnancy.

If a patient becomes pregnant while taking medication for AUD, continuing treatment during pregnancy requires informed decision-making after weighing the risks to the fetus and the benefits to the pregnant patient [Kelty, et al. 2019]. With effective pharmacologic treatment, a pregnant patient may be able to reduce or abstain from alcohol use, which may improve maternal health and will minimize fetal exposure to alcohol and the risk of associated harms, such as FASD [Reece-Stremtan and Marinelli 2015; WHO 2014].

Breastfeeding: The effects of alcohol use during lactation are complex, and there is conflicting evidence on the effects of infant exposure to alcohol in breast milk [May, et al. 2016; Haastrup, et al. 2014]. Alcohol is excreted into breast milk in concentrations similar to those in parental blood, which means that the amount of alcohol ingested by an infant through breast milk is a fraction of the amount consumed by the parent. Alcohol can disrupt breastfeeding by decreasing milk production and let down [LactMed(a) 2022]. However, the effect of occasional alcohol consumption on milk production appears small, temporary, and clinically irrelevant [Haastrup, et al. 2014].

The American Society of Addiction Medicine recommends that patients who use alcohol and are breastfeeding wait for 2 hours per drink after drinking [Miller 2018]. For example, after 2 drinks, the individual should wait for at least 4 hours before breastfeeding. Breast milk can also be pumped and discarded after alcohol consumption. However, there is little clinical evidence to suggest that breastfed children are adversely affected by occasional alcohol use [Haastrup, et al. 2014]. Over-the-counter test strips are available to measure alcohol in breastmilk, but there are no clinical studies currently available on the use of the test strips.

Breastfeeding while taking acamprosate is not recommended. It is unknown if breastfed infants are exposed to acamprosate through breast milk [FDA 2004]. Naltrexone use is not contraindicated during breastfeeding; limited data indicate that naltrexone is minimally excreted into breast milk [LactMed(a) 2021].

Tobacco Use Disorder Treatment During Pregnancy

Clinicians should advise pregnant patients who use tobacco to abstain from or minimize use during pregnancy. Tobacco and nicotine use during pregnancy has been linked to low birth weight, preterm birth, placental abruption, miscarriage, stillbirth, sudden infant death syndrome, poor fetal neurodevelopment, and a variety of congenital disabilities [Akerman, et al. 2015; Cressman, et al. 2012; Forinash, et al. 2010].

Treatment of Other Substance Use Disorders During Pregnancy

Few data are available on the risks of active cannabis use while breastfeeding, and no clear guidance is available on the length of time to wait after cannabis use before breastfeeding; when counseling patients, it is important to discuss potential risks and benefits, reasons for cannabis use, and possible alternatives to use [LactMed(d) 2022; Metz and Borgelt 2018; ACOG(b) 2017]. Breastfeeding is not advised for individuals actively using cocaine or methamphetamine.

There are no U.S. Food and Drug Administration (FDA)-approved medications to treat stimulant use disorders (e.g., cocaine, amphetamine, and methamphetamine). A recent clinical trial found a potential benefit associated with bupropion and naltrexone in treating methamphetamine use disorder [Trivedi, et al. 2021]. No pregnant patients were included in the study.

Referral options include inpatient withdrawal management, an intensive outpatient substance use disorder (SUD) treatment program, treatment for a mental health condition and SUD (for patients with dual diagnosis), support groups (e.g., 12-step, SMART Recovery), apps (e.g., SMART Recovery, In the Rooms), public health nursing, community-based care management, peer support, recovery coaching, and any other psychosocial supports. Behavioral interventions, such as cognitive-behavioral therapy, motivational interviewing, and contingency management, may also play a role in assisting a pregnant patient to minimize substance use [WHO 2014].

All Recommendations

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Supplementary Material

Supplement: Guideline Development and Recommendation Ratings