CNE

Pharmacologic Treatment of Opioid Addiction During Pregnancy

Lori Keough

Heidi Collins Fantasia

Objectives

Upon completion of this activity, the learner will be able to:

1. Describe special considerations of medication-assisted treatment of pregnant women with

opioid addiction.

2. List differences between methadone and buprenorphine treatment.

3. Outline pertinent elements of a nursing care plan for a pregnant woman with opioid

addiction.

Continuing Nursing Education (CNE) Credit

A total of 1.1 contact hours may be earned as CNE credit for reading “Pharmacologic Treatment

of Opioid Addiction During Pregnancy” and for completing an online posttest and participant

feedback form.

To take the test and complete the participant feedback form, please visit

http://www.awhonn.org/?OnlineLearningCenter. Certificates of completion will be issued on

receipt of the completed participant feedback form and any processing fees.

Association of Women’s Health, Obstetric and Neonatal Nurses is accredited as a provider of

continuing nursing education by the American Nurses Credentialing Center’s Commission on

Accreditation.

Accredited status does not imply endorsement by AWHONN or ANCC of any commercial

products displayed or discussed in conjunction with an educational activity.

AWHONN is approved by the California Board of Registered Nursing, provider #CEP580.

Lori Keough, PhD, MEd, FNP-BC, PMHNP-BC, is an assistant professor in the College of

Health Sciences, School of Nursing at the University of Massachusetts, Lowell, and she is a

nurse practitioner for the University of Massachusetts Medical School in Worcester, MA. Heidi

Collins Fantasia, PhD, RN, WHNP-BC, is an assistant professor in the College of Health

Sciences, School of Nursing at the University of Massachusetts, Lowell, and a nurse practitioner

for Health Quarters in Beverly, MA. The authors and planners of this activity report no conflicts

of interest or relevant financial relationships. No commercial support was received for this

learning activity. Address correspondence to: Lori_Keough@uml.edu.

http://dx.doi.org/ 10.1016/j.nwh.2016.12.010

© 2017, AWHONN

Abstract: Opioid addiction during pregnancy presents a treatment challenge to clinicians and

women alike. Untreated addiction can lead to poor maternal and fetal health outcomes.

Medication-assisted treatment is the standard of care, and methadone is the current drug of

choice for treatment. Emerging evidence also supports the use of buprenorphine during

pregnancy. Both methadone and buprenorphine have risks and benefits that should be explored

before initiating treatment. Clinicians who work in obstetrics and in addiction treatment can

collaborate and coordinate treatment to ensure optimal maternal and fetal outcomes. Women

undergoing treatment will require frequent monitoring, particularly in the third trimester.

Neonates born to women receiving treatment may have withdrawal symptoms and require

additional treatment.

Keywords: buprenorphine | medication-assisted treatment | methadone | opioid | pregnancy

Introduction

Opioid abuse in the United States is a serious public health issue. Approximately 1.9 million

individuals in the United States have a substance use disorder involving prescription pain

relievers, and an additional 586,000 have a substance use disorder involving heroin (Centers for

Disease Control and Prevention [CDC], 2015). Women and men of all ages, including

adolescents, are affected; however, according the CDC (2013), the most dramatic increase in

opioid use has been among women. For the years spanning 1999 through 2010, heroin use in

women increased 400%, more than double the rate in men (CDC, 2013). In addition, women are

more likely than men to be prescribed opioid pain relievers for chronic pain, to use more of

them, and to use them for longer periods of time, leading to an increased risk of dependency

(CDC, 2013).

According to the Substance Abuse and Mental Health Services Administration (SAHMSA;

2014), many women who use opioids are of childbearing age. Some women with substance use

disorders have an unmet need for effective contraception, thus placing them at risk for

unintended pregnancy (Terplan, Hand, Hutchinson, Salisbury-Afshar, & Heil, 2015). When

women with addiction experience abrupt discontinuation of opioids during pregnancy, they may

also experience poor fetal outcomes such as an increased risk of intrauterine passage of

meconium and neonatal aspiration, abruptio placentae, intrauterine growth restriction, preterm

labor and birth, fetal distress, or fetal demise (American College of Obstetricians and

Gynecologists [ACOG] Committee on Health Care for Underserved Women& American Society

of Addiction Medicine, 2016; Kocherlocota, 2014). Further, if a woman uses opioids by

injection, this increases her risk of contracting HIV, hepatitis C, injection site abscess, sepsis,

and endocarditis (CDC, 2013). All of these conditions can negatively affect maternal and fetal

health outcomes.

This article focuses on the pharmacologic treatment of opioid addiction during pregnancy.

Although complete cessation of all opioid use during pregnancy is the optimal scenario, abrupt

withdrawal of opioids can be harmful for both a woman and fetus (Zedler et al., 2016). Although

a variety of treatment modalities exist that include both pharmacologic and psychosocial

interventions, this article addresses treatment with methadone and buprenorphine, the two most

common medications used to treat opioid addiction during pregnancy.

Pharmacology

All opioids, including heroin and prescription opioid pain relievers, bind to opioid receptors in

the brain. The primary receptors are mu-opioid receptors. They are well-populated in areas of the

brain that perceive and regulate pain, including emotional responses to pain. Further, mu

receptors are concentrated in the reward region of the brain that mediates perception of pleasure

and well-being. This is strongly associated with repeated use, because an individual associates

opioids with these desirable effects in the brain (Akil et al., 1984). Receptors are also populated

in the brain stem where respiration is controlled. When receptors are oversaturated with more

opioids than can be processed, respiratory depression and death can occur.

Tolerance, Dependence, and Addiction

Over time, the repeated administration of any opioid will result in tolerance and dependence.

Tolerance refers to an individual’s response to a drug so that he/she needs to administer more of

a substance to get the desired effect. Dependence occurs after repeated use when adaptations in

the brain trigger physical withdrawal symptoms if the substance is not used (Volkow &

McLellan, 2016). The time from the beginning of opioid use to dependence is highly variable,

and many factors are associated with this complex phenomenon, such as type of opioid, dose,

and exposure frequency. What is inevitable, however, is that with repeated exposure the

adaptations in opioid receptors will result in both tolerance and physical dependence (Volkow &

McLellan, 2016). The mechanism for addiction is a very different pathway than that of tolerance

and dependence. Also, although tolerance and dependence are predictable, addiction is not and

occurs in only a small percentage of those who use opioids (Volkow & McLellan, 2016).

Addiction is characterized by obsessive thinking and pronounced craving for the substance and

includes a loss of inhibitory control over efforts to refrain from drug and compulsive drug taking

(American Psychiatric Association, 2013).

Treatment for Opioid Addiction in Pregnancy

Untreated opioid withdrawal in the fetus can lead to poor fetal outcomes including preterm labor,

fetal growth restrictions, abruptio placentae, and intrauterine passage of meconium (ACOG

Committee on Health Care for Underserved Women & American Society of Addiction

Medicine, 2016; Kocherlakota, 2014). Because of the risks associated with an untreated opioid

addiction, it is recommended that all women with opioid addiction receive medication-assisted

treatment, which combines behavioral therapy and medications to treat substance use disorders.

The recommendations for pregnant women to initiate or continue on maintenance treatment

come from a joint committee opinion paper from the ACOG Committee on Health Care for

Underserved Women and the American Society of Addiction Medicine (2016) .

In September 2013, the U.S. Food and Drug Administration placed a black box warning, the

highest level of warning, on the class of extended-release and long-acting opioid analgesics to

describe the risk of neonatal opioid withdrawal syndrome, also referred to as neonatal abstinence

syndrome. Precautionary statements about neonatal opioid withdrawal syndrome are in the

Warnings and Precautions, Pregnancy, and/or Drug Abuse and Dependence sections of the

prescribing information for all long-acting opioid analgesics. In addition to the expanded section

on the risk of neonatal opioid withdrawal syndrome, a black box warning also highlights the

addiction risk, potential for respiratory depression, and possibility of fatal overdose among

individuals who use these medications.

Although pregnancy categories are no longer being used clinically, both methadone and

buprenorphine were classified as Category C. Under the current expanded labeling system, this

means that adequate studies have not been conducted in pregnant women. Animal studies

suggest an increased mortality in rodent offspring when high maternal doses are given, but

animal models do not necessarily predict human outcomes. Previous researchers have suggested

that supervised use of opioid medications such as methadone and buprenorphine is unlikely to

cause a significant teratogenic risk during pregnancy (Lo & Friedman, 2002). More recently,

researchers have suggested that opioid use during pregnancy may be linked to cardiac

abnormalities, but no direct causation has been established. Multiple confounding issues such as

polysubstance abuse among study participants, small sample sizes, and the observational nature

of the research limits conclusive evidence of a link between opioids and congenital abnormalities

(Viteri et al., 2015).

Methadone

Methadone is an opioid agonist that is metabolized by the liver. It has a long and variable half-

life, anywhere from 8 to 59 hours. It is water soluble, and it accumulates in the liver and in fatty

tissue (lipophilic), and has a relatively low molecular weight. Methadone is a highly regulated

Schedule II medication that can only be dispensed in a licensed methadone treatment center or

clinic that has strict oversight by state and federal agencies (Wiegand et al., 2015). There are

some differences depending on in which state a clinic is located. However, in general, patients

must go to their treatment center daily between specified hours to receive their prescribed dose

of methadone. There are some provisions for take-home medications, and these are strictly

monitored with clear guidelines, but they are not often used with pregnant women. Methadone is

dispensed via an electronic dispensing mechanism by a licensed practical nurse or a registered

nurse and is monitored by a physician, physician’s assistant, or advanced practice registered

nurse; counseling is a required part of treatment.

The use of methadone as a treatment for opioid addiction during pregnancy has been the standard

of care since the 1970s. The risks of methadone use in pregnancy are not well documented

despite almost 50 years of use. Broussard et al. (2011) documented the risks of short-acting

opioids with a small relative risk in congenital malformations but not absolute risk, and only in

short acting opioids; however, no data on dose and frequency of use were reported. Despite low

rates of teratogenic outcomes, it is widely understood that neonatal opioid withdrawal syndrome

occurs in up to 94% of newborns born to women who use methadone (Kocherlakota, 2014).

If a woman begins methadone while pregnant, the dosage is typically initiated at 10 to 30 mg per

day and titrated until she is asymptomatic, meaning she is having no signs or symptoms of opioid

withdrawal. Although there are no universal recommendations, it is understood that pregnant

women should be closely monitored, usually monthly, particularly in the third trimester (ACOG

Committee on Health Care of Underserved Women& American Society of Addiction Medicine,

2016). There is no ceiling for methadone dosing in pregnancy, and there does not appear to be a

correlation between methadone dose and neonatal opioid withdrawal syndrome severity

(Kocherlakota, 2014). Methadone providers are responsible for titrating the dosage to the lowest

amount that controls withdrawal symptoms and drug cravings (ACOG Committee on Health

Care for Underserved Medicine& American Society of Addiction Medicine, 2016). Too low of a

dosage can lead to mild to moderate opioid withdrawal and may cause fetal distress and

increased risk of illicit maternal opioid use. Conversely, an excessive dosage can cause sedation

and respiratory depression and daytime sleepiness.

Methadone also has the potential to interact with other medications. Methadone is mostly

metabolized in the liver via the N-demethylation by the cytochrome P450 (CYP) 3A4 system,

which varies among individuals and accounts for differences in methadone metabolism. In

addition, the CYP2D6 and probably CYP1A2 systems are also involved in methadone

metabolism, and treatment with other drugs may be influenced, including psychotropic drugs,

antibiotics, anticonvulsants, and antiretroviral drugs, which are also CYP2A4 inducers. If a

woman is already taking methadone before pregnancy, her dosage is likely to be increased

during pregnancy because the bioavailability of methadone is reduced in pregnancy. Although

pregnancy is known to affect hepatic drug metabolism, the underlying mechanisms are not well

understood for all drugs, including methadone.

Physiologic changes during pregnancy that may affect drug-metabolizing enzymes include

elevated concentrations of estrogen, progesterone, placental growth hormones, and prolactin.

This is particularly true in late pregnancy, when binding of methadone to plasma proteins

decreases plasma levels. Although the mechanism is poorly understood, it is thought that

elevated levels of progestin can affect transporter metabolizing enzymes and influence hepatic

drug metabolism (Hyunyoung, 2010; Kreek, 1983). Therefore, women need to be monitored

more carefully during pregnancy, at least monthly, to make sure their dosage is adequate and that

they are not experiencing cravings and are attending their prenatal appointments.

Buprenorphine

Buprenorphine, a Schedule III medication, is a partial agonist at the mu receptors and antagonist

at kappa receptors. It is an opioid agonist–antagonist and currently can be prescribed only by

accredited physicians who have undergone specific credentialing and training. Additionally, it is

the only opioid approved for the treatment of opioid dependence in an office-based setting. The

U.S. Food and Drug Administration has approved both single and combination buprenorphine

products. The combination products, which contain buprenorphine and naloxone, come in

sublingual/buccal transmucosal films and tabs. The naloxone included in the combination

product has poor bioavailability when taken sublingually or orally and is included to prevent

diversion and abuse. It is activated and causes withdrawal symptoms when crushed or injected.

At the time of this writing, buprenorphine products cannot be prescribed by midlevel providers

such as nurse practitioners, certified nurse-midwives, and physician assistants; however, there is

legislation pending that may lift this restriction in the near future.

Although methadone is the standard of care for medication-assisted treatment of pregnant

women in the United States, buprenorphine is also used to treat opioid addiction during

pregnancy. Buprenorphine has been approved by the U.S. Food and Drug Administration for

medication-assisted treatment in the United States since 2002. There is emerging evidence

supporting the use of single-product buprenorphine, rather than combination products, for

treatment of pregnant women (Soyka, 2013). The use of naloxone with buprenorphine in

pregnant women is generally not recommended, because theoretically naloxone may cross the

placenta and precipitate withdrawal in the fetus (Hyunyoung, 2010). However, researchers who

conducted a recent review of buprenorphine and buprenorphine/naloxone concluded that there

were no significant differences in adverse maternal and fetal outcomes between buprenorphine

monotherapy and buprenorphine/naloxone combination therapy (Lund et al., 2013).

Differences Between Treatment With Methadone Versus Buprenorphine

Both methadone and buprenorphine have a place in the treatment of pregnant women with opioid

addiction (Holbrook, 2015). A major barrier to treatment during pregnancy includes a lack of

treatment centers that can accommodate treatment of pregnant women (Willson & Thorp, 2008),

and this may be a factor when selecting a therapy. For example, if there is no health care

provider who is willing to prescribe buprenorphine to pregnant women or no certified provider in

the geographic area, methadone may be the only option. Regardless of what medication they are

using, pregnant women should be given treatment priority, especially if provider panels and

spaces in treatment centers are limited.

In general, there are some fundamental differences between the two treatment regimens for all

women, as well as caveats to consider when treating pregnant women (see Table 1). Because

methadone is a highly controlled and regulated medication, it can be dispensed only in a licensed

facility when prescribed for opioid abuse. In most cases, this will require that the individual go to

a clinic daily, although take-home medication privileges can be earned for some people who are

receiving treatment. However, pregnancy in and of itself does not meet criteria for take-home

treatment. Buprenorphine is prescribed in an office environment and typically requires a

minimum of monthly visits to an authorized prescriber.

From a safety perspective, methadone has drug interactions and can cause corrected QT interval

prolongation and sedation. Buprenorphine carries some safety concerns as well, including drug

interactions and potential for abuse, particularly during pregnancy, and buprenorphine

combination products are not recommended in pregnancy so as to avoid fetal exposure to the

naltrexone that is present in them. However, potential advantages of buprenorphine over

methadone include a lower risk of overdose, fewer potential drug interactions, the availability of

office visits, and the potential for less severe symptoms of neonatal opioid withdrawal syndrome

in the neonate (Kocherlokata, 2014). Potential disadvantages include the possible altered hepatic

function, potential for increased dropout rates due to dissatisfaction with the drug, and decreased

adherence compared with methadone regimens (Fowler et al., 2013).

Methadone presents some challenges as well. There is a less flexible treatment regimen than

buprenorphine, which can be prescribed monthly like most other medications. Compared with

buprenorphine, methadone may have an increased potential for abuse and overdose, for more

drug interactions, and for a more prolonged course of neonatal opioid withdrawal syndrome

(Holbrook, 2015; Wiegand et al., 2015; Zelder et al., 2016). Researchers have also reported

higher doses of medication required to treat neonatal opioid withdrawal syndrome in neonates

born to mothers using methadone over buprenorphine (Jones et al., 2010). Regardless of which

medication is chosen, there are federal guidelines that apply to both medications (Substance

Abuse and Mental Health Services Administration, 2015). Generally, policies include the initial

dose for a newly admitted pregnant woman and effective dosing protocols. Women are

encouraged to continue treatment postpartum; however, there is currently a lack of data to

measure adherence to this recommendation.

Neonatal Considerations

Neonatal opioid withdrawal syndrome, a transient and curable condition, occurs in neonates

when a pregnant woman takes opioid drugs. These can include both illegal and legal substances

such as heroin, codeine, oxycodone, fentanyl, morphine, methadone, or buprenorphine

(Kocherlakota, 2014). Because these drugs pass through the placenta to a fetus, a neonate can be

addicted along with the mother. When a newborn stops receiving the opioid via maternal

transmission after birth, he or she can exhibit symptoms of withdrawal, which may include

tremors, poor feeding, vomiting, irritability, disrupted sleep, fever, and inability to be consoled

and soothed. Signs and severity of withdrawal are variable and typically begin 1 to 3 days after

birth, but they may occur up to 1 week after birth. Symptom severity varies among individuals

and is contingent upon many different factors, including which drug was used, how much of it,

how the body metabolized it, and duration of use (Akil et al., 1984). Gestational age at birth also

affects the severity. Because of the immaturity of all systems, premature infants have more

severe symptoms (Kocherlakota, 2014).

Breastfeeding

Breastfeeding has specific benefits for women and newborns during treatment for opioid abuse.

Breastfeeding promotes bonding and may also help decrease symptoms associated with neonatal

opioid withdrawal syndrome (Welle-Strand et al., 2013). Women receiving medication-assisted

treatment in the postpartum period are encouraged to breastfeed their infants regardless of their

opioid dosage (ACOG Committee on Health Care for Underserved Women & American Society

of Addiction Medicine, 2016; Tsai & Doan, 2016). However, there is a need to understand that

medication is excreted in breast milk and that if there is an abrupt cessation, a newborn may

experience symptoms of opioid withdrawal if the mother is receiving high doses of medication-

assisted treatment. As infants are weaned from breast milk and gradually introduced to solids

during the natural course of infant feeding, they are then weaned off of the medication as well.

Implications for Nursing Practice

Regardless of whether nurses interact with women during the prenatal period, during labor and

birth, or during the postpartum period, nonjudgmental and supportive care and communication

are essential. Pregnant women with substance use disorders are often judged harshly and

stigmatized by family, friends, society, and even health care providers, who may see the opioid

abuse as a weakness that needs to be punished rather than a health condition that needs to be

treated (Jones et al., 2010). In some states, opioid abuse during pregnancy is criminalized, further

adding to stigma, suspicion of health care providers, removal of children from the home, and

reluctance to enter care (Kremer & Arora, 2015; Martin & Finlayson, 2015). When a trusting

relationship is built between women and their providers, there is a greater chance of accurate

disclosure of drug use, increased attendance at prenatal appointments, and greater adherence to

opioid treatment (Krans, Cochran, & Bogen, 2015).

Intrapartum and postpartum management require that health care providers, including nurses

who are providing direct care, know what pharmacologic treatment a woman is receiving.

Because methadone is not prescribed in a traditional sense, using a prescription monitoring

program or contacting the patient’s pharmacy will not reveal any information related to

methadone. However, if a woman is being treated with buprenorphine, her medical, dosage, and

prescription histories would be readily available. Careful documentation by prenatal care

providers is essential so that information is available to those providing care during the

intrapartum and postpartum periods. Pain management in the intrapartum and postpartum periods

is as if the woman were not receiving medication-assisted treatment, because the maintenance

doses would not provide analgesia (ACOG Committee on Health Care for Underserved

Women& American Society of Addiction Medicine, 2016). Short-term use of opioids for pain

relief should be administered during labor if requested. In fact, women with opioid use disorders

will likely need higher doses of any pain medications to achieve analgesia because of their

tolerance and poor receptor availability (ACOG Committee on Health Care for Underserved

Women & American Society of Addiction Medicine, 2016). It is particularly important to ensure

that the woman not receive agonist–antagonist drugs such as nalbuphine, butorphanol, or

pentazocine, because they can precipitate withdrawal.

Ideally, women should be working with their obstetric health care providers and truthfully

disclosing their substance use. In general, obstetric providers do not treat a woman’s drug

addiction, and similarly, an addiction specialist will not treat pregnancy-related issues.

Therefore, it is important that frequent communication be maintained between the woman’s

obstetric care provider and the addiction medicine provider to coordinate care. The federal

confidentiality law 42 CFR Part 2 applies to addiction treatment providers and, according to the

law, patient information release forms with specific language regarding substance use are

required (United States Government Publishing Office, 2016).

Nurses who work with women receiving treatment with either methadone or buprenorphine are

in a position to provide ongoing education in addition to support and nonjudgmental care.

Although treatment is dispensed in an office or clinic setting under supervised conditions,

women should be advised of serious adverse effects, especially respiratory depression, if taken

concurrently with central nervous system depressants. These include alcohol, other narcotic

medications, sedatives, and hypnotic sleep aids. Using other medications with abuse potential or

using illicit drugs during treatment places a woman at risk for relapse. Medication lists should be

reviewed with women at each visit.

Conclusion

Opioid addiction is a chronic long-term brain disease that requires treatment in all populations,

including pregnant women. Medication-assisted treatment has been, and continues to be, the

standard of care in women presenting with opioid addiction, including addiction during

pregnancy. The treatment benefits far outweigh the risks in both the infant and the mother if the

addiction is not addressed. The benefits include the prevention of maternal and fetal risks

associated with active opioid use such as infection, inconsistent prenatal care, IUGR, preterm

birth, and prolonged neonatal withdrawal. Care for pregnant women with opioid addiction should

include a combination of pharmacologic and psychosocial interventions delivered in a supportive

and nonjudgmental environment.

Table 1. Differences Between Methadone and Buprenorphine

Methadone Buprenorphine

Dosage Varies by individual

Starting at 5–20 mg daily

Maintenance can exceed 100 mg daily

Varies by individual

Starting at 2–8 mg daily

Maintenance up to 24 mg daily max

Treatment setting Federally licensed treatment program Medical office setting

Schedule Schedule II: highly regulated Schedule III: included in physician

monitoring programs

Metabolism Liver, CYP459, 3A4 substrate Liver extensively, CYP450, 3A4

substrate

Excretion Feces, urine (pH dependent)

Slow release from the liver

Bile/feces (70%), urine (30%)

Half-life Highly variable, 8–59 hours 20–44 hours

Risk for adverse

neonatal outcomesa

Decreased head

circumference

Higher

Lower

Low birth weight

Spontaneous

death

Fetal anomalies

Drop-out rate

and satisfaction

Higher

No difference

No difference

Lower drop-out rate, greater satisfaction

Lower

No difference

No difference

Higher drop-out rate, less

satisfaction

Costb Varies by clinic

$42,541 (includes costs of neonatal care

postpartum)

Varies by provider

$30,061 (includes costs of neonatal

care postpartum)

Medication

monitoring

No specific laboratory testing

recommended

EKG to evaluate QTc at baseline and

every 1–2 years thereafter

Liver function tests at baseline and

periodically thereafter

Those with liver function 3–5 times

above normal may not be candidates

for buprenorphine

Adverse effects Common

Sedation

Constipation

Common

Sedation

Depression

Bradycardia

Diaphoresis

Lightheadedness

Withdrawal with abrupt

discontinuation

Serious

Torsades de Pontes/prolonged

QTc

Respiratory depression/arrest

Seizures

Hypotension

Headache

Constipation

Withdrawal with abrupt

discontinuation

Serious

Respiratory depression/arrest

Hepatoxicity/hepatitis

Adrenal insufficiency

Note. CYP = cytochrome P450; EKG = electrocardiography; max = maximum; QTc =

corrected QT interval.

aSource: Zedler et al., 2016.

bSource: Fowler et al., 2013.

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Posttest

1. From 1999 through 2010, by how much did heroin use increase among women?

a. 40%

b. 200%

c. 400%

2. Which of the following characterizes substance tolerance?

a. A need to use more of a substance to get the desired effect

b. Physical withdrawal symptoms occur if the substance is not used

c. Obsessive thinking and pronounced craving for the substance

3. Which best describes medication-assisted treatment for substance use disorders?

a. Inpatient treatment with medications to “detox” a person from substances

b. Outpatient treatment that combines medications with behavioral therapy

c. Outpatient treatment with medications to “detox” a person from substances

4. In up to what percentage of neonates born to women using methadone does neonatal opioid

withdrawal syndrome occur?

a. 9%

b. 49%

c. 94%

5. What is likely to occur if a pregnant woman presents who has already been taking methadone

before becoming pregnant?

a. Her prescribed dosage is likely to be decreased during pregnancy.

b. Her prescribed dosage is likely to be increased during pregnancy.

c. Her prescribed dosage is likely to remain the same during pregnancy.

6. What is one potential effect of the physiologic changes of pregnancy for women receiving

methadone treatment that indicates the need for careful monitoring during pregnancy?

a. A decrease in a woman’s cravings for opioids

b. An increase in levels of progestin can affect transporter metabolizing enzymes and influence

hepatic drug metabolism

c. An increase in the toxicity of opioids

7. Which is considered the standard-of-care drug treatment of choice for treating opioid addiction

in pregnant women?

a. Buprenorphine alone

b. Buprenorphine with naloxone

c. Methadone

8. Which do the authors cite as a major barrier to medication-assisted treatment of opioid

addiction in pregnant women?

a. Clinician bias toward undertreatment of pregnant women with drug addiction

b. Cost of treatment

c. Lack of treatment centers that can accommodate treatment of pregnant women

9. Which is true of methadone treatment compared with buprenorphine?

a. It can be dispensed only by physicians.

b. It could result in more severe symptoms of neonatal opioid withdrawal syndrome.

c. It is a more flexible treatment regimen than buprenorphine.

10. What is an important consideration for breastfeeding during medication-assisted treatment

for opioid addiction?

a. Abrupt discontinuation of medication-assisted treatment can cause a breastfeeding newborn to

experience symptoms of opioid withdrawal.

b. Breastfeeding is discouraged because opioids are excreted in breast milk.

c. Breastfeeding newborns tend to experience more symptoms of opioid withdrawal.