If opioids (fentanyl) and want to continue using:

1. Replace their opioid
   1. hydromorphone 4-8 mg PO q 1-2 hrs PRN
   2. You will likely need to increase that dose so do not hesitate to go up if necessary (up to 8-12 mg PO q 1 hr PRN)

If opioids (fentanyl) and want to start Medication Assisted Therapy (MAT):

1. With methadone (time of last use doesn’t matter)
   1. Get an EKG to evaluate QTs interval (consider buprenorphine if QTC > 500)
   2. Day 1: methadone 40 mg and in 4 hrs repeat 20 mg PRN x1
   3. Day 2: methadone 60 mg and in 4 hrs repeat 20 mg PRN x1
   4. Day 3: methadone 80 mg and in 4 hrs repeat 20 mg PRN x1
   5. Day 4: methadone 100 mg. Obtain a second EKG for QTc interval
   6. Opioid replacement during this induction of methadone
   7. Will need referral to an approved methadone treatment clinic
2. With buprenorphine (if less than 24 hours since last use)
   1. Start with micro-induction:
      1. Buprenorphine 0.5 mg SL q 4 hrs for 24 hrs
      2. Then buprenorphine 1 mg SL q 4 hrs x 24 hrs
      3. Then buprenorphine 2 mg SL q 4 hrs x 24 hrs
      4. Opioid replacement during this induction of buprenorphine.
3. Adjunctive medications for withdrawal (usually 4-12 hrs after last use):
   1. Clonidine 0.1 mg PO q 6 hrs prn
   2. Gabapentin 300 mg PO q 6 hrs prn
   3. Cyclobenzaprine 5-10 mg q 8 hrs prn
      1. Can use Tizanidine 4 mg PO q hrs prn, discuss feeding plans w/patient as it is an L4 med
   4. Hydroxyzine 25-50 mg PO q 6 hrs prn

Post-operative management in the first 24 hrs

1. Consider continuous epidural x 24 hrs
2. Consider TAP block by anesthesia
3. Multimodal pain mgmt: APAP, ketorolac, opioids if necessary

If > 24 hours since last use, follow BRIDGE protocol for buprenorphine start. Can use either Suboxone® (Buprenorphine / Naloxone) or Subutex® buprenorphine) in pregnancy.

1. Start buprenorphine 8mg sublingual
2. Rescore COWS q 1 - 1.5 hours and redose Suboxone 4mg SL q 1 - 1.5 hours: GOAL IS 80% REDUCTION OR SCORE < 5.
   TOTAL MAX DOSE OF 12mg ON DAY 1
3. NST prior to discharge if ≥ 23-24 weeks
4. Rx provided for total dose given on induction day (NOTE ALL SUBOXONE SCRIPTS MUST BE WRITTEN AS q DAY DOSING)

Multidisciplinary team care model

1. Team to include social workers, psychiatry, MFM, addiction resources in your area.
2. Local outpatient referral centers, suggest biannual review of local resources to keep up to date.
   1. Example: Nexus Recovery https://nexusrecovery.org/
      1. Residential, medical, psychiatry, outpatient, childhood development center

Clinical Considerations

1. Avoid Nubain and Stadol (partial antagonist and can put patient in withdrawal)
2. Consider use of TAP/QL blocks, enhanced recovery pathways with around the clock Tylenol 1000mg q6 hours/Ibuprofen 600mg q6 hours
3. Pain management post cesarean section, shared decision making with patient. Opioid dependent patients require higher doses.
4. Discharge home with Narcan, link to goodrx.com for free Narcan kits
5. FDA has now approved Narcan nasal spray[2]

Other Considerations for Management

• Florida Perinatal Quality Collaborative

• Buprenorphine quick start guide in pregnancy
• Counseling and shared decision-making guide
• COWs score (clinical opiate withdrawal scale)
• NIDA screening tool (National Institute on Drug Abuse)
• Postpartum pain management
  • https://www.mcpapformoms.org/docs/MCPAP_for_Moms_Toolkit_SUD_Treatment_Provider.pdf
  • https://www.mcpapformoms.org/docs/Management_of_Pain_During_and_After_Deli...
  • https://bridgetotreatment.org/resource/acute-pain-management-in-patients-on-buprenorphine-ed-critical-care/

Comprehensive Toolkits

CA Bridge Treatment Protocols

CQMCC (California Maternal Quality Care Collaborative)

OUD Clinical Care Checklist example. CMQCC referencing Illinois

MCPAP for Moms Complete Toolkit (Massachusetts Child Psychiatry Access Program) Substance abuse disorders and pernatal mental health

Notable association guidelines

• ACOG
  • Opioid Use and Opioid Use Disorder in Pregnancy. Committee Opinion. Number 711. August 2017, reaffirmed 2021. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use- disorder-in-pregnancy
• AIM
  • Care for Pregnant and Postpartum People with Substance Abuse Disorder. https://saferbirth.org/wp-content/uploads/R3_AIM_Bundle_CPPPSUD_Resources.pdf
• SAMHSA
  • Evidence-based, Whole-Person Care for Pregnant People who Have Opioid Use Disorder. SAMHSA Advisory. March 2024. https://store.samhsa.gov/sites/default/files/whole-person-care-pregnant-pe...
• Washington State Health Association
  • Sample Guideline for Opioid Use Disorder in Pregnancy. https://www.wsha.org/perinatal-substance-use-disorder-learning-collaborative/