In an MDEdge/Ob-Gyn conference review emphasizing use of naltrexone as medication-assisted treatment (MAT), Dr. Craig Towers asserts that management of pregnant women with opioid use disorder (OUD) can include prenatal withdrawal from the opioid being used.  The report describes naltrexone induction in lieu of opioid agonist (buprenorphine, methadone) management.  I’m not sure that this is right.  His reasoning centers on the low likelihood of intrauterine demise, and concludes that this can be accomplished safely.  However, the objective of intervention with an OUD must take into account not merely the fetus’s welfare, but also the longer-term issues of the mother’s recovery and her ability to remain free from illicit, unmonitored opioid use.  The risks of relapse are of course comorbidity acquisition (HIV, hepatitis, sepsis) in the short term; and loss of maternal and household stability in the longer term, stability repeatedly demonstrated to improve with maintenance opioid agonist medication.  What appears needed  is evidence that naltrexone maintenance can achieve comparable stability over the long run.

In reviewing his comments, discussion with Dr. Tricia Wright (DFASAM) led to her co-authored review article in May (Terplan M. et al., Opioid Detoxification During Pregnancy,  Obstetrics and Gynecology 2018 May; 131(5):803-814).  It provided these conclusions:  “Evidence does not support detoxification as a recommended treatment intervention as a result of low detoxification completion rates, high rates of relapse, and limited data regarding the effect of detoxification on maternal and neonatal outcomes beyond delivery.” 

- W. Haning, MD