Opioids During Pregnancy: Risks, Withdrawal, and What You Need to Know

When a pregnant person is using opioids - whether prescribed for pain or as part of an opioid use disorder - the stakes are high. Not just for them, but for the baby growing inside. The fear isn’t just about addiction. It’s about what happens after birth: a newborn trembling, screaming, unable to eat or sleep. This isn’t rare. In the U.S., neonatal opioid withdrawal syndrome (NOWS), once called neonatal abstinence syndrome (NAS), has increased fivefold since 2010. Today, about 7 out of every 1,000 babies born in hospitals show signs of withdrawal. That’s tens of thousands of infants every year.

What Happens When Opioids Cross the Placenta

Opioids - including prescription painkillers like oxycodone, illegal drugs like heroin, and medications like methadone or buprenorphine - pass easily through the placenta. The baby’s body gets used to them, just like the parent’s. When the baby is born and that steady supply stops, the nervous system goes into overdrive. That’s NOWS. Symptoms usually show up 48 to 72 hours after birth. They’re not subtle: high-pitched crying, fever over 37.2°C, breathing faster than 60 breaths per minute, loose stools more than three times an hour, and jittery movements that won’t stop. Some babies can’t even be comforted by holding or feeding.

It’s not just about discomfort. Babies with severe withdrawal can have seizures, poor weight gain, and longer hospital stays - sometimes over three weeks. And while these symptoms are scary, they’re treatable. The goal isn’t to avoid all opioids during pregnancy - it’s to manage them safely.

Medication-Assisted Treatment Is the Standard - Not Withdrawal

For years, the idea was to get pregnant people off opioids completely. That changed. In 2017, the American College of Obstetricians and Gynecologists (ACOG) made it official: medically supervised withdrawal is dangerous. It increases the risk of miscarriage, preterm labor, and fetal distress. Relapse rates jump to 30-40% after withdrawal, putting both mother and baby at greater risk.

Today, the gold standard is medication-assisted treatment (MAT). Two medications are used: methadone and buprenorphine. Both are opioid agonists - they activate the same brain receptors as heroin or oxycodone, but more steadily and safely. They reduce cravings, prevent withdrawal, and help people stay in care.

Methadone is usually started at 10-20 mg per day and slowly increased to 60-120 mg. Buprenorphine starts lower - 2-4 mg sublingually - and can go up to 8-24 mg daily. Both are taken daily under supervision. Studies show MAT cuts relapse by 60-70% compared to quitting cold turkey. Babies born to people on MAT weigh about 200-300 grams more, are born closer to full term, and have larger head circumferences.

Comparing Methadone and Buprenorphine

Not all MAT is the same. Methadone and buprenorphine have different effects on the baby.

Methadone leads to more severe withdrawal symptoms in newborns. On average, babies exposed to methadone have Finnegan scores (a standard tool to measure withdrawal) of 14.3, compared to 11.8 for buprenorphine. Hospital stays are longer - 17.6 days versus 12.3 days. But methadone keeps more people in treatment. About 70-80% stay on it after six months, compared to 60-70% with buprenorphine.

Buprenorphine is easier to access. It can be prescribed by primary care doctors, not just specialized clinics. It’s also safer in overdose. But it still causes withdrawal in 50-80% of babies, and about half of those need medication to manage symptoms.

There’s a third option: naltrexone. It’s an opioid blocker, not an agonist. It doesn’t activate receptors - it blocks them. A 2022 Boston Medical Center study found that infants exposed to naltrexone had a 0% rate of NOWS during hospitalization. Their mothers were more likely to breastfeed successfully, and babies went home in just two days on average. But here’s the catch: these mothers started treatment later - at 28.4 weeks on average - compared to 19.7 weeks for those on buprenorphine. That delay raises red flags. Starting naltrexone too early can trigger withdrawal in the fetus, which is risky. It’s promising, but not yet recommended as a first-line treatment during early pregnancy.

Monitoring the Baby After Birth

Every baby exposed to opioids in the womb needs careful monitoring after birth. The CDC says: at least 72 hours. That’s not optional. Hospitals using the Eat, Sleep, Console method - which focuses on whether the baby can feed, sleep for more than an hour, and be calmed without medication - have reduced the need for drugs by 30-40%.

Assessments happen every 3-4 hours in the first 24 hours, then every 4-6 hours after that. The Finnegan scale is still used in many places, but it’s flawed. A 2021 study found 37 different scoring systems across U.S. hospitals. That inconsistency means one baby might get medication in one hospital and be sent home in another.

Non-drug care comes first. Skin-to-skin contact, swaddling, dim lights, quiet rooms, and frequent feeding help. If the baby can’t sleep for an hour, can’t be consoled, or is losing weight, then medication like morphine or methadone may be needed. But it’s a slow wean - often over weeks. One parent on a recovery forum described her baby’s 14-day morphine taper as “terrifying.” Another said her baby needed 19 days of treatment.

Breastfeeding and Opioids

Can you breastfeed if you’re on methadone or buprenorphine? Yes. The amount of drug that passes into breast milk is very low - less than 1% of the maternal dose. The American Academy of Pediatrics says breastfeeding is encouraged for mothers on MAT. It helps calm the baby, reduces withdrawal severity, and strengthens bonding.

But not everyone gets support. Over half of mothers in recovery forums say they felt judged or discouraged from breastfeeding. Some providers still wrongly assume it’s unsafe. It’s not. Naltrexone users had an 83% success rate with breastfeeding - and no withdrawal symptoms. That’s a powerful combination.

The Bigger Picture: Access, Stigma, and Trauma

Getting treatment isn’t just about medicine. It’s about housing, transportation, mental health, and not being treated like a criminal. In 2021, only 45% of U.S. hospitals had standardized protocols for managing opioid use in pregnancy. In rural areas, that number drops to 28%. Many women don’t even get to their first prenatal visit until 20 weeks - too late for the best outcomes.

And stigma? It’s real. One mother shared that her OB said, “You’re lucky your baby is alive.” Another said a nurse refused to hold her newborn because she was “on drugs.” These moments don’t just hurt - they push people away from care.

Depression and trauma are common. Over 30% of pregnant women in substance use programs screen positive for moderate to severe depression. Nearly 42% report postpartum depression. Treatment must include therapy, peer support, and safe spaces - not just pills.

New Hope: Extended-Release Buprenorphine and Integrated Care

There’s progress. In 2023, the FDA approved Brixadi, an extended-release form of buprenorphine given as a weekly or monthly injection. In trials, 89% of pregnant women stayed on treatment at 24 weeks - much higher than with daily pills. This could be a game-changer for those who struggle with daily dosing.

The NIH’s HEALing Communities Study is testing full integration: prenatal care, MAT, mental health, housing help, and peer coaching - all in one place. Early results show a 22% drop in NAS severity when all these pieces work together. That’s not just better for babies - it’s better for families.

What’s clear now is this: opioid use during pregnancy isn’t a moral failure. It’s a medical condition. And like diabetes or high blood pressure, it can be managed. With the right care, mothers stay stable. Babies are healthier. Families stay together.