Substance Use Care After Delivery

The baby is here, and someone wants the methadone or buprenorphine cut today, or stopped so you can breastfeed. Do not change the dose on your own. Tell the clinician if you are drowsy. A dose that worked in pregnancy may need a change, and that change is individual.

If you or the baby will not wake, look blue, or are breathing slowly, call 911. Keep naloxone where opioids are in the house. How to recognize that emergency is in opioid overdose signs. For a mental health crisis, call or text 988.

Drowsiness is a reason to be seen, not a chart to follow

In the first days, drowsiness or sleeping for unusually long periods should prompt a look at the agonist dose. A dose that worked in pregnancy may be too high after delivery. You might also be exhausted because the newborn does not sleep. Because doses before delivery vary, clinicians are advised to use signs of oversedation when they consider a change. Evidence for lowering methadone or buprenorphine after delivery is mixed. When oversedation is reported, the dose can be adjusted by the clinician who can see you. If you are breastfeeding and look oversedated, both you and the baby should be assessed. Ask for a follow-up as early as possible after discharge.

Avoid alcohol and sedating medicines, especially benzodiazepines, while you are on an opioid agonist. SAMHSA says that combination is especially dangerous to breastfed infants. Do not add those drugs because the nights are hard.

Care before the birth, including why these medicines are not quit in a panic, is in rehab during pregnancy. What the medicines are is in medication for opioid use disorder.

Cravings are not a reason to switch medicines tonight

Cravings, even without a return to use, may make you ask for a different medicine. Cravings alone do not justify the switch. The current dose should be checked, and it may be adjusted. New stress after the birth is a reason for more behavioral support. If you want a different form of the same medicine, the reasons and risks should be discussed with your other clinicians, with your permission, before anyone acts. Cost and prior authorization can stall a switch. The paperwork should be finished before the old medicine stops, so there is no gap.

If you are stable on methadone or buprenorphine and want to move to naltrexone, the risk of returning to use is high. That change should not be made without a compelling reason. If you are not stable, the factsheet points to more behavioral support and to dose changes aimed at cravings or withdrawal, not to a casual stop.

People sometimes feel they no longer need the medicine once the pregnancy is over. Women with opioid use disorder should continue the medicine as prescribed after the baby is born, and stopping it in the days right after delivery should generally be avoided. Plans to stop are made with the treatment team. The taper is gradual, to prevent withdrawal. A safety plan for you and your family comes first, including what you will do if opioid use returns. Discontinuation should at least wait until the baby is consistently sleeping through the night and breastfeeding is done, and until several parts of life look stable. The longer you continue the medicine, the lower the risk SAMHSA describes when you later choose to taper. People can stay on pharmacotherapy for months, a year, or longer.

Breastfeeding is often advised, and it is not every case

Upon delivery, women who are stable on buprenorphine, on buprenorphine with naloxone, or on methadone should be advised to breastfeed, if appropriate. Levels of those medicines in milk are described as very low. The combination with naloxone is not, by itself, a reason to stop nursing. Any breastfeeding, even a short time, can reduce the infant's need for medicine for neonatal abstinence and can shorten that treatment. SAMHSA attributes that benefit to the feeding itself, including holding the baby, rather than to the amount of medicine in the milk. The infant's condition is in neonatal opioid withdrawal.

Naltrexone in breast milk has not been studied extensively in the United States. Unless safety is a concern, agonist therapy should not be stopped early just to start another medicine. Some women want to taper while nursing. The amount of prescribed medicine the baby gets through milk is described as extremely small, while harm from a return to use is much greater. That is not permission to taper alone.

Breastfeeding is not recommended in every situation. The factsheet's examples include HIV, tuberculosis, cracked or bleeding nipples, and a return to illicit drug use, including cannabis. Mothers with hepatitis B or hepatitis C may breastfeed, and the factsheet points to the American Academy of Pediatrics and CDC for those lines. Ask. Do not apply both kinds of statements as a ruling you make alone.

The return-to-use rate for women with a substance use disorder increases after delivery. SAMHSA cites Helmbrecht and Thiagarajah, 2008, for that rise. Postpartum depression and the stress of parenting can affect the risk. Support may need to last past the traditional six-week visit. Tell someone if mood, sleep, or cravings change. Peer support can help with triggers and with locking medicine away from children. It is not a prescriber.

Contraception belongs in the discharge conversation, and it must be non-coercive. Questions about a plan of safe care, which is a different federal framework, are in plans of safe care. State rules differ.

Search FindTreatment.gov for care that will keep treating opioid use disorder after delivery. Call or text (800) 653-9376 if you need help finding that care. Do not stop the medicine while you wait.

Additional Resources

Sources cited on this page:

• SAMHSA: Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants (SMA18-5054)
• CDC: Treatment of opioid use disorder before, during, and after pregnancy
• SAMHSA FindTreatment.gov
• 988 Suicide & Crisis Lifeline

Common Questions