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Methadone substitution treatment of opioid use disorder during pregnancy

Neil S Seligman, MD
Vincenzo Berghella, MD
Section Editors
Susan M Ramin, MD
Andrew J Saxon, MD
Deputy Editor
Vanessa A Barss, MD, FACOG


Methadone is a synthetic opioid agonist used for medical withdrawal and substitution treatment of opioid use disorder (heroin or other morphine-like drugs), along with appropriate social and medical services. Methadone substitution therapy has many potential benefits during pregnancy and postpartum (table 1). Nevertheless, several barriers to methadone treatment exist, including lack of health insurance, incarceration, transportation and childcare needs, guilt about the effect of drugs on the fetus, and fear of legal consequences, including loss of custody of children.

This topic will review management of methadone substitution therapy in pregnant and postpartum women. The choice of methadone versus buprenorphine substitution therapy and management of buprenorphine substitution therapy are discussed separately. (See "Buprenorphine substitution therapy in pregnancy".)

Methadone is also an option for treatment of moderate to severe chronic pain during pregnancy when alternative treatment options are inadequate [1]; this indication is beyond the scope of this topic.


The two main approaches to treatment of opioid use disorder during pregnancy are opioid substitution therapy (with either methadone or buprenorphine) and medical withdrawal. Both approaches involve substituting a prescribed opioid for illicit opioids. In opioid substitution therapy, the opioid is administered in doses sufficient to prevent symptoms of withdrawal and reduce or eliminate drug craving. In medical withdrawal, the opioid dose is gradually reduced to the lowest dose that prevents withdrawal symptoms and then reduced further until the drug can be discontinued. These two approaches have never been compared in a randomized trial involving pregnant women.

Opioid substitution therapy is considered the standard of care for pregnant women with opioid use disorder [2-4]. Although medical withdrawal reduces neonatal sequelae of maternal opioid use [5-11], a major drawback is the high proportion of women who return to using illicit opioids [5,12]. (See 'Medical withdrawal' below.)


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