Opioids During Pregnancy: Risks, Withdrawal, and What Care Looks Like Today

When a pregnant person is using opioids-whether prescribed for pain or misused as part of a substance use disorder-the stakes aren’t just personal. They’re biological, medical, and deeply human. The baby growing inside isn’t just exposed to the drug; their entire nervous system is adapting to it. And when that drug is removed or reduced, the baby doesn’t just cry-they go through withdrawal. This isn’t rare. It’s common. And it’s treatable.

Why Opioids During Pregnancy Are a Medical Issue, Not a Moral One

Opioid use disorder (OUD) in pregnancy isn’t about poor choices. It’s about a brain chemistry that’s been rewired by chronic use, often starting long before pregnancy. People don’t wake up one day and decide to get addicted. Addiction develops slowly, and for many, it’s tied to untreated trauma, chronic pain, or mental health conditions like depression. The CDC reports that between 2010 and 2020, the rate of neonatal abstinence syndrome (NAS)-also called neonatal opioid withdrawal syndrome (NOWS)-rose fivefold in U.S. hospitals. That’s not because more people are using drugs. It’s because we’re finally seeing them.

The biggest mistake? Trying to quit cold turkey. Medically supervised withdrawal during pregnancy increases the risk of miscarriage by up to 4%, preterm labor by 10%, and fetal distress by nearly 15%. It also pushes relapse rates to 30-40%. That means a woman might spend weeks in detox, only to return to opioids because the cravings and anxiety are unbearable. And when that happens, the baby is exposed again-this time, to even higher doses.

Medication-Assisted Treatment: The Gold Standard

The medical community agrees: the best way to protect both mother and baby is with medication-assisted treatment (MAT). That means using FDA-approved medications like methadone or buprenorphine to stabilize opioid levels without causing highs or withdrawal. These aren’t substitutes-they’re treatments. Think of them like insulin for diabetes. You don’t stop insulin because you’re pregnant. You adjust it.

Methadone has been used for decades. It’s taken daily in liquid form under supervision. Doses usually start between 10-20 mg and are slowly increased to 60-120 mg daily. It’s effective at keeping mothers in care-70-80% stay in treatment after six months. But babies born to mothers on methadone often have more severe withdrawal symptoms. On average, they stay in the hospital 17.6 days, and their Finnegan scores (a tool that measures withdrawal severity) average 14.3.

Buprenorphine is newer and often preferred. It’s taken as a dissolving tablet under the tongue. Doses typically range from 8-24 mg daily. It’s easier to manage, has fewer side effects for the mother, and results in slightly less severe withdrawal in newborns. Babies stay in the hospital about 12.3 days on average, with Finnegan scores around 11.8. But here’s the catch: only 60-70% of mothers stay in treatment with buprenorphine after six months, compared to 70-80% with methadone.

There’s a third option: naltrexone. It’s not an opioid. It blocks opioids from working. Some women use it during pregnancy, and the results are striking. In one 2022 study, none of the babies born to mothers on naltrexone showed signs of withdrawal. They went home after two days. But here’s the trade-off: women on naltrexone often start treatment later-around 28 weeks-compared to 19-20 weeks for those on methadone or buprenorphine. That means less time for the baby to benefit from stable maternal health.

What Neonatal Withdrawal Actually Looks Like

When a baby is born after being exposed to opioids, their body doesn’t know how to function without them. Symptoms usually show up 48-72 hours after birth. They’re not just fussy. They’re physiological.

• Temperature above 37.2°C
• Respiratory rate over 60 breaths per minute
• More than three loose stools per hour
• Excessive crying that can’t be soothed
• Tremors, seizures, or stiff muscles

Doctors use scoring systems like the Finnegan scale to track these symptoms. But here’s the problem: there are 37 different scoring systems used across U.S. hospitals. One baby might be assessed every 3 hours in one hospital, and every 6 in another. That inconsistency makes it harder to predict outcomes or compare treatments.

Newer approaches like the Eat, Sleep, Console model are changing that. Instead of counting every sneeze or cry, providers ask: Can the baby eat? Can they sleep for more than an hour? Can they be comforted? If yes, they don’t need medication. Hospitals using this method have cut the need for drugs like morphine or methadone to treat withdrawal by 30-40%.

What Happens After Birth?

The work doesn’t stop at delivery. Babies need to be monitored for at least 72 hours. In the first 24 hours, they’re checked every 3-4 hours. After that, every 4-6 hours. If symptoms get worse, they’re started on medication-usually morphine or methadone-and slowly weaned over days or weeks.

One mother on Reddit described her baby scoring 12 on the Finnegan scale at 48 hours. “It was terrifying,” she wrote. “They gave him morphine. We held him through the weaning. It took 14 days.” Another shared that her baby needed 19 days of treatment. These aren’t outliers. They’re routine.

But not all stories are dark. One woman on a recovery forum said her baby on naltrexone had zero withdrawal symptoms. “We went home after two days. He slept through the night. I breastfed him. It felt normal.”

Can You Breastfeed?

Yes. Most women on methadone or buprenorphine can safely breastfeed. The amount of drug that passes into breast milk is tiny-far less than what the baby was exposed to in the womb. The American Academy of Pediatrics says breastfeeding is encouraged, as long as the mother isn’t using other substances, smoking, or has HIV.

Breastfeeding can even help with withdrawal. Skin-to-skin contact, feeding on demand, and rhythmic sucking calm the baby’s nervous system. One study found that 83% of mothers on naltrexone successfully breastfed without complications. That number is high because naltrexone doesn’t cross into milk at all.

But stigma is real. Many women report being told not to breastfeed, even when it’s safe. Some are even questioned about their parenting skills. That kind of judgment makes recovery harder.

Where Care Falls Short

The science is clear. The guidelines exist. But access? That’s another story.

Only 45% of U.S. hospitals have standardized protocols for managing opioid use in pregnancy. In rural areas, that number drops to 28%. Many clinics don’t have addiction specialists on staff. Some don’t even offer buprenorphine. Medicaid covers MAT for pregnant women under the 2020 SUPPORT Act-but only 32 states fully comply.

And then there’s the mental health gap. Over 30% of pregnant women in substance use treatment screen positive for moderate to severe depression. More than 40% develop postpartum depression. Without integrated mental health care, recovery is fragile. A woman might stay sober through pregnancy, only to relapse after the baby is born because no one asked how she was feeling.

What’s New in 2025?

In 2023, the FDA approved Brixadi, the first extended-release buprenorphine injection for pregnant women. Given once a week, it eliminates the need for daily dosing. Early trials show 89% of women stayed in treatment at 24 weeks, compared to 76% with daily pills. That’s a big win.

The NIH’s HEALing Communities Study, running through 2025, is testing full-service care models-where prenatal care, MAT, mental health, housing help, and peer support are all in one place. Early results show a 22% drop in NAS severity when care is coordinated.

But the biggest breakthrough isn’t a drug. It’s a shift in thinking. We’re moving from punishment to care. From judgment to support. From seeing addiction as a failure to recognizing it as a medical condition that needs treatment-especially when a baby’s life is on the line.

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

• Don’t stop on your own. Withdrawal is dangerous for you and your baby.
• Ask for MAT. Methadone or buprenorphine are safe and effective.
• Start care as early as possible. First prenatal visit is ideal.
• Ask if your hospital uses the Eat, Sleep, Console method.
• Yes, you can breastfeed. Ask for support.
• Get mental health care. Depression and anxiety don’t disappear after birth.
• You are not alone. Thousands of women have done this. Recovery is possible.