Toolkit: Medication-Assisted Recovery/Treatment For Opioid Use Disorder (OUD)

Community: Perinatal

MOUD Intake (Not Already Diagnosed with OUD)VideoFlowchartResources
MOUD Intake (Already Diagnosed with OUD)VideoFlowchartResources
MOUD InitiationVideoFlowchartResources
MOUD Ongoing CareVideoFlowchartResources

Perinatal MOUD Intake (Not Already Diagnosed with OUD)

Perinatal
MOUD Intake (Not Already Diagnosed with OUD)

Patient

Is pregnant patient already diagnosed with OUD and receiving treatment?

No

empty

Yes

Screen for substance use with validated tools such as 5Ps, NIDA Quick Screen, CRAFFT (for persons under age 26).

Universal urine drug screens not recommended

(results do not indicate presence or absence of OUD)


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If positive screen

MOUD Provider

Ask questions (DSM-5) to determine if OUD is present.

If OUD diagnosed

Administer other recommended screens if possible and educate patient on all available MOUD options (handout).

Buprenorphine and methadone are FDA approved as first line OUD treatments with no increase in risks of birth defects or adverse long-term developmental impacts.

Naltrexone is FDA approved for OUD, but not recommended to initiate during pregnancy. Medically supervised withdrawal (detox) + abstinence is discouraged due to high rate of return to use.

Other recommended screens
(but not mandatory for initiating MOUD)

Mental Health
(e.g., PHQ-9, GAD-7)

Infections
(e.g., Hep B, Hep C, and HIV)

Fetal Assessment
(e.g., ultrasound, doppler)

Patient chooses buprenorphine

Patient chooses methadone

Discuss possible formulations.

Bup mono (Subutex) is safe and effective w/o harm to fetus, according to large-scale human studies. It has a higher potential for misuse (i.e., intravenous injection and diversion) than bup combo.

Bup combo (Suboxone) is safe and effective w/o harm to fetus, according to human case reports and small-scale human studies. It is more commonly prescribed than bup mono, which might make it easier for the patient to obtain.

Bup injectable (Sublocade) has no reported adverse effects on fetus (evidence from human case reports), but animal studies have shown birth defects in 1st trimester. For pregnant patients who continue to use or have barriers to cessation, this option may be advantageous as it decreases overdose risk, which outweighs the theoretical (not yet proven) risk of injectable bup.

If access to inpatient setting is available, patients can be admitted to rapidly titrate up to a stable methadone dose using this guide before bridging to a methadone treatment center (MTC).

Otherwise, patients must be referred to an MTC for initiation.

If patient chooses either bup mono or bup combo,


Go to third workflow: Perinatal MOUD Initiation.</a >

If patient chooses bup injectable, click here for further guidance.

If at any point, you need assistance with initiating MOUD treatment or providing follow-up or ongoing care management for your patient, contact MAR-NOW or IllinoisDocAssist.

Perinatal MOUD Intake (Already Diagnosed with OUD)

Perinatal
MOUD Intake (Already Diagnosed with OUD)

Pregnant patient is already diagnosed with OUD and is receiving treatment.

Is patient stable on naltrexone, bup mono, bup combo, or methadone?

Yes

No

Continue with same treatment plan and ensure patient has access to naloxone.

As the pregnancy progresses, split dosing and dose increases for bup mono, bup combo, and methadone may be needed.

Is patient on bup injectable?

Yes

Discuss with patient the theoretical risks (i.e., animal studies have shown birth defects in 1st trimester, but no reported adverse effects on fetus from human case reports).

For pregnant patients who continue to use or have barriers to cessation, this option may be advantageous as it decreases overdose risk, which outweighs the theoretical (not yet proven) risk of injectable bup.

Document risk-benefit discussion in chart.

Does patient wish to continue bup injectable?

Yes

No

Continue with same treatment plan and
ensure patient has access to naloxone.

Switch to bup mono or bup combo and
ensure patient has access to naloxone.

As the pregnancy progresses, split dosing and dose increases may be needed.

If at any point, you need assistance with initiating MOUD treatment or providing follow-up or ongoing care management for your patient, contact MAR-NOW or IllinoisDocAssist.

Perinatal MOUD Initiation

Perinatal
MOUD Initiation

Patient has chosen either the bup mono or bup combo.

Review IL PMP to assess recently prescribed controlled substances. Although unexpected findings should not prevent MOUD initiation, be sure to have a risk-benefit discussion with patient and document in chart.

Identify where the patient will be initiated.

Has patient voiced intentions to immediately stop illicit opioid use?

Yes

No

Use Standard Dose Initiation

Educate patient on initiation process (handout), explaining need to wait until moderate withdrawal (i.e., COWS > 12 or SOWS > 11).

For fentanyl users, this can take 48-72 hours. Offer comfort meds (e.g., acetaminophen, diphenhydramine, clonidine, hydroxyzine, loperamide, and ondansetron) and ensure patient has access to naloxone.

When in moderate withdrawal, begin with daily dose of 12-16 mg bup.

Follow up daily via text or phone until patients’ withdrawal symptoms and cravings are controlled, increasing dose up to 24 mg if needed.

Use Low Dose Initiation

Educate patient on 7-14 day low dose
protocol (example).

Document rationale for use of this strategy (e.g., “patient unable to abstain from full agonist for appropriate timeframe”), offer comfort meds (e.g., acetaminophen, diphenhydramine, clonidine, hydroxyzine, loperamide, and ondansetron), and ensure patient has access to naloxone.

Immediately begin with Day 1 dose of bup.

Follow up daily for the next 7-14 days via text or phone to check patient’s progress with low dose protocol, providing support as needed.

If at any point, you need assistance with initiating MOUD treatment or providing follow-up or ongoing care management for your patient, contact MAR-NOW or IllinoisDocAssist.

Perinatal MOUD Ongoing Care

Perinatal
MOUD Ongoing Care

Antepartum Care (Late Second/Early Third Trimester)
Higher MOUD doses (e.g., 24-32 mg bup) and/or higher frequency dosing may be needed due to changes in metabolism and renal clearance during pregnancy. Ask patient about withdrawal symptoms and cravings, increasing timing and dosing of bup/methadone as needed. Reassure patients that higher/more frequent doses have not been shown to increase the newborn’s severity of Neonatal Opioid Withdrawal Syndrome (NOWS).

Prior to Labor

Discuss with patient (and the delivering provider) that MOUD should be continued during labor & delivery and which options below should be used to control labor & delivery pain. (Note: MOUD will not fully address pain).

Offer neuraxial anesthesia (epidural, spinal) and/or nitrous oxide as first line modalities. Okay to use full agonists (e.g., morphine, dilaudid, fentanyl).

Use non-opioid modalities too. (e.g., IV acetaminophen and transverse abdominis plane blocks)

Avoid partial agonists because they can cause precipitated withdrawal.
(e.g., nalbuphine, butorphanol and pentazocine)

Postpartum Care

Pain Control

For vaginal deliveries, continue MOUD + non-opioid options (e.g., acetaminophen, ibuprofen, ice-packs and sitz baths).

For more severe pain (e.g., C-section, higher order perineal tears),

  • consider IV acetaminophen and ketorolac for 48 hours,
  • consider full opioid agonists (e.g., hydromorphone), noting that up to 50% higher doses may be needed to achieve adequate analgesia, and
  • address patient’s concerns about use of full agonists (i.e., won’t cause withdrawal, but may increase cravings).

Breastfeeding & Other Interactions

If patient is stable on MOUD with no recent use of illicit substances, encourage breastfeeding, which can reduce the severity of NOWS.

Encourage rooming-in, skin to skin, and low lights/reduced stimuli, which can also reduce severity of NOWS and improve patient’s mental health.

Reporting Requirements

Any newborn with a positive toxicology test for any controlled substance must be reported to IDPH through APORS. Generally, your hospital will have a process for this. If birthing patient is stable on prescribed MOUD, there is no requirement for a DCFS report if no other illicit substances are present. DCFS must be contacted if illicit substances are present or there is concern for the newborn’s wellbeing.

Reassure patient that a report to IDPH or DCFS does not mean the newborn will be automatically separated from their parents; it just means that an investigation may be opened.

Continued Care

Continue follow-up with patient to retain in OUD treatment, as MOUD reduces chance of opioid overdose death by 60%.

Offer contraception to decrease unintended pregnancies (e.g., long-acting reversible contraceptive such as an IUD or a subdermal progesterone implant).

If at any point, you need assistance with initiating MOUD treatment or providing follow-up or ongoing care management for your patint, contact MAR-NOW or IllinoisDocAssist.