AANA October 2025 Journal Course: Methadone or Buprenorphine: Equal in Treating Opioid Dependent Parturients?-Methadone or Buprenorphine: Equal in Treating Opioid Dependent Parturients?

Methadone or Buprenorphine: Equal in Treating Opioid Dependent Parturients?

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This AANA Journal article (October 2025) reviews the comparative pharmacology, maternal and neonatal outcomes, and treatment management considerations of methadone versus buprenorphine for opioid use disorder (OUD) in pregnant women. OUD in pregnancy has sharply increased, resulting in significant health risks and increased healthcare costs, with nearly 6 in 1,000 births affected and about $1.5 billion annual costs. The American College of Obstetricians and Gynecologists (ACOG) recommends opioid pharmacotherapy with methadone or buprenorphine over medically supervised withdrawal due to withdrawal's high maternal-fetal risks such as relapse, fetal hypoxia, preterm labor, and stillbirth.<br /><br />Methadone is a full opioid agonist with a long half-life, metabolized hepatically, requiring clinic visits and has stricter regulation, whereas buprenorphine is a partial agonist with a ceiling effect on respiratory depression, fewer regulatory constraints, office-based prescribing, and generally better safety profiles. Both medications effectively reduce withdrawal symptoms and cravings, but buprenorphine has lower overdose risk, less neonatal abstinence syndrome (NAS), and improved neonatal outcomes such as larger head circumference, shorter hospital stays, and less need for NAS treatment. Methadone is associated with higher retention rates, making it more effective in polysubstance users, but carries increased risks such as respiratory depression and maternal overdose. <br /><br />Opioid detoxification during pregnancy is not recommended due to high relapse and overdose rates and risks of fetal harm. Management with medication-assisted treatment (MAT) using methadone or buprenorphine is the standard of care. Emerging practices include cautious switching from methadone to buprenorphine during pregnancy via microdosing to avoid withdrawal. Breastfeeding is encouraged for mothers on either medication, with higher breastfeeding rates observed in buprenorphine-treated women.<br /><br />Treatment choice should be individualized considering patient access, substance use history, socioeconomic factors, and regulatory barriers. Disparities exist, with buprenorphine more likely prescribed to older, employed, and white women, reflecting inequities in healthcare access. Recent legal changes have eased prescribing restrictions for buprenorphine, potentially expanding access. Overall, current evidence suggests that buprenorphine offers superior neonatal outcomes with comparable maternal outcomes to methadone, although methadone may improve treatment retention. Providers must balance these factors to optimize care for pregnant patients with OUD.

Keywords

opioid use disorder

pregnancy

methadone

buprenorphine

maternal outcomes

neonatal outcomes

medication-assisted treatment

neonatal abstinence syndrome

opioid pharmacotherapy

treatment retention