Safer Solutions: In Pregnancy and Recovery, Put Health and Safety First—and Hold the Judgment

Ask anyone who has been visibly pregnant, and they’ll tell you that people have a lot of opinions about how they should behave. Even mundane activities like exercising or drinking coffee spark urges to pass judgment on activities that people assume put the developing fetus at risk.

These instincts are supercharged when it comes to opioid use during pregnancy, and those judgments and fears can lead us to the wrong conclusions about the safest course of action. Opioid use disorder (OUD) can pose serious risks to parent and fetus. But when it comes to managing OUD during and after pregnancy, what we think people should do can end up causing greater harm.

In today’s Safer Solutions, we’ll talk about:

• The risks of opioid misuse in pregnancy and where they stem from
• Why “Just stop using!” poses more risks than it hopes to resolve
• Why experts recommend medications for opioid use disorder (MOUD) as the best course of action

Risks of Opioid Misuse During Pregnancy

Untreated OUD in pregnancy poses serious risks to all involved. Some of these harms come from the drugs themselves and are exacerbated by the ever-changing illicit drug supply. Its unpredictability has contributed to increases in overdose; in fact, opioid overdose is a leading cause of maternal death during and after pregnancy. In babies, opioid exposure before birth can increase the risk of low birth weight, stillbirth, and withdrawal syndrome.

Beyond the drugs themselves, our systems teach parents to fear punishment for seeking help. The very real risk of punitive actions like criminalization or loss of parental rights due to substance use can make people less likely to disclose and seek help for their OUD during and after pregnancy or to access prenatal care.

“Just Stop Using!” Is Dangerous Advice

But isn’t the safest option to simply quit using drugs upon becoming pregnant? “Any good parent would try to quit,” the thinking goes. Indeed, people who use drugs are “generally highly motivated” to attempt to quit when they learn they’re pregnant; however, if quitting were easy, we’d see a lot more of it. The reality is that “just stop” is dangerous advice, especially during pregnancy. It might seem paradoxical, but attempting to quit during pregnancy heightens the risk of relapse and overdose, jeopardizing the life and health of all involved.

Insistence on quitting during pregnancy can also fuel “repeated cycles of withdrawal, which can lead to… a cascade of events that can culminate in preterm birth and low birth weight,” according to Dr. Mishka Terplan, who spoke on a recent R Street panel about pregnancy and MOUD.

Treatment That Works

Experts consider MOUD (e.g., buprenorphine and methadone) optimal for treating opioid use in pregnancy. These medications can reduce or eliminate the misuse of drugs and reduce overdose risk by up to 80 percent. MOUD use during pregnancy reduces risks of preterm birth and low birth weight. Offering MOUD helps create a trusted circle of care, making patients more likely to access prenatal care and to continue treatment and attend well-child visits after giving birth. MOUD also increases the likelihood that families will stay together.

Any medication taken in pregnancy can pose some risk to newborns. But with MOUD, these risks tend to be limited and manageable. Symptoms of MOUD withdrawal don’t appear in every newborn, but when they do, they are treatable. In many cases, it’s also safe to breastfeed while on MOUD, which benefits both mother and baby and can help reduce the severity of withdrawal symptoms.

More Work to Do

Today, only 50 to 60 percent of pregnant women with OUD receive MOUD. Stigma and misinformation around MOUD in pregnancy make some people hesitant to seek it and some providers hesitant or unwilling to prescribe it. Better access to and less overregulation of these medications would help, as would an increase in specialized treatment and recovery options for people who are pregnant or parenting.

Changes in how our healthcare, legal, and child welfare systems treat pregnancy and OUD would also help expand the use of these medications. Too many providers default to reporting patients to punitive systems rather than supporting them through evidence-based healthcare. This creates more risks and harm by discouraging people from seeking help for their OUD.

For people already taking MOUD when they become pregnant, fears of punishment or loss of custody can lead to the “dangerous choice” to stop their medication. Between June 2022 to June 2023, 133 women in the United States were prosecuted for substance use in pregnancy alone (no allegations of harm to the fetus or newborn), and of those criminally charged, 16 were taking MOUD. Beyond criminal charges, some governments remove children from their parents’ custody simply because they followed doctor’s orders: In Kentucky, providers reported nearly 700 women to authorities for taking prenatal MOUD from 2017 to 2020; in Arizona, 16 babies “exposed only to methadone” were taken from their parents in 2021 and 2022 as a result of provider reporting.

As with so much in harm reduction, we have tools to empower families to be healthier and whole. Our assumptions, communications, education, and public policy must reflect what’s truly best for parents and babies. This requires us to set aside judgment and shame in favor of what the evidence clearly shows.

Read more from our R Street colleagues:

“How Prenatal Substance Use Laws Inadvertently Endanger Healthy Families”