The opioid crisis and rise in overdose deaths in recent years has received a great deal of media attention. Though the media has helped to raise awareness, it has also contributed to stigmatization of individuals struggling with addiction. Pregnant and parenting women are among those who have been severely affected by the epidemic and perhaps most shamed by society for their use.

Sadly, at a time when many women feel motivated to connect with the health care system and make healthy choices, women with addiction often avoid interacting with providers due to feelings of shame and mistrust. There are many misconceptions regarding the risks and benefits of medical treatment for women with substance use disorders as well as the treatment of neonatal withdrawal. We hope to dispel some of these myths and provide a better understanding of the evidence supporting the treatment of substance use disorders in the setting of pregnancy as well as neonatal withdrawal.

Myth 1: Medications for opioid use disorder should be stopped in pregnancy to protect the fetus

As obstetric and family medicine physicians who care for women with substance use disorders during their pregnancy, we often meet women asking to discontinue their medications for opioid use disorder (OUD). This request generally stems from women wanting to do everything they can to have healthy babies, misunderstanding the safety and benefits of medications in pregnancy, stigma surrounding opioid use disorder in pregnancy, and fears of child protective services becoming involved at time of delivery.

Pregnancy is a unique and highly motivating time in a woman’s life; many may be entering the health care system formally for the first time in years, and even before a heartbeat can be detected, women express a great attachment to their pregnancy. Though a happy time for many, women with OUD can find this to be a time of great stress. Pregnant and with a history of addiction, women often experience feelings of shame and guilt—they are not sure what to tell their friends and family, they are fearful of exposing their baby to medications, and they worry they will lose custody of their baby. While clinicians may emphasize that addiction is a chronic disease that is prone to flares—relapses—just like diabetes or heart disease, many women believe pregnancy can motivate them to abstain from substances and enter remission. This may be true for some women, but opioid use disorder is a brain-altering disease¹⁰ and willpower alone is typically not enough. The American College of Obstetricians and Gynecologists and several other national organizations recommend methadone and buprenorphine—Subutex—as first-line treatment options for opioid use disorder in pregnancy.¹  Both have been shown to reduce use of illicit substances in pregnancy and improve outcomes for the fetus and both reduce rates of overdose and improve rates of long-term remission. Medically-assisted withdrawal—gradual taper off of medication—is not recommended in pregnancy due to high rates of relapse.⁶ Counseling women about the known safety profile of methadone and buprenorphine in pregnancy¹⁴ and the known benefits of staying on an adequate dose of medication is a big part of our job.

Myth 2: Babies are born “addicted”

This concept has gotten a lot of press lately as the opioid epidemic skyrockets and more women have a diagnosis of opioid use disorder at time of delivery. Since the early 2000s, the country has seen the number of babies who are born with neonatal abstinence syndrome (NAS) rise dramatically from about 1 to 2 in 1,000 deliveries up to over 6 in 1,000 deliveries—a five-fold increase.⁹

The widely-used term NAS is a misnomer as a baby cannot be addicted to a drug—i.e., have cravings or repeated drug use despite negative consequences—just as the baby cannot choose to be “abstinent.” A more medically precise term is starting to get more traction—NOWS, or Neonatal Opioid Withdrawal Syndrome. This more accurately describes the fact that babies born to women who either use illicit opioids or are prescribed opioids during their pregnancy and become dependent on the opioids they are exposed to in utero and will, therefore, go through withdrawal. Why is this difference so important to point out? Because words matter. There is a growing body of literature that demonstrates how impactful the language we chose is on perpetuating stigma and shame for women with opioid use disorder.^7,8,2

Myth 3: Treatment of neonatal withdrawal always requires medication and long hospital stays

The treatment of babies with neonatal opioid withdrawal is evolving. Historically, treatment for neonatal opioid withdrawal occurred in the nursery or intensive care unit for close monitoring—essentially, away from the mother. In a paradigm shift, mom is becoming first-line treatment for neonatal opioid withdrawal.¹³ There is growing evidence that nonpharmacologic treatment for neonatal withdrawal is effective; for some babies, nonpharmacologic treatment is so effective that no medication is needed, and they can go home within four to seven days of birth. Nonpharmacologic treatment includes keeping babies in an environment with low stimulation and providing typical comfort measures such as swaddling, breastfeeding, and holding. In fact, holding a baby can be so effective to manage mild withdrawal symptoms that hospitals now have “cuddler” programs so that babies don’t miss out on this important treatment when parents can’t be at their bedside. When babies are showing signs of more significant withdrawal—difficulty eating, difficulty being consoled despite above measures, or not sleeping⁴—then they sometimes need medication in addition to nonpharmacologic treatment. Common medications include, but are not limited to, morphine and methadone.

Myth 4: A higher medication dosage will lead to more severe neonatal withdrawal

There are also some misconceptions about which babies will have worse symptoms of withdrawal—i.e., require more medication and remain in the hospital longer. Women commonly worry about increasing doses of their medication—methadone, buprenorphine—because they fear that a higher dose will lead to worse withdrawal symptoms in babies. However, studies have shown that the dose does not correlate with the severity of withdrawal.³ There is some evidence that babies exposed to buprenorphine have less severe withdrawal than those exposed to methadone in utero.⁵  And, newer research is coming out that shows that genes probably play a significant role in the severity of withdrawal, independent of other factors.¹² Finally, many people don’t realize that tobacco, benzodiazepines, selective serotonin reuptake inhibitors (SSRIs), gabapentin, and other substances have been shown to increase the severity of neonatal withdrawal and that much of the more severe symptoms we see in neonates is likely a combination of genetic predisposition and multiple exposures.¹¹

The bottom line is:

• Experts recommend mothers stay on maintenance treatment—methadone, buprenorphine—for their opioid use disorder to prevent relapse or other consequences of drug use in pregnancy.
• Babies cannot be born “addicted.”
• Neonatal withdrawal from opioids is a treatable, time-limited, and expected outcome for opioid exposure in utero.