Pregnant Woman with Opioid Use Disorder and Limited Access to Care
A 28-year-old woman at 24 weeks gestation presents to the emergency department with signs of opioid withdrawal (yawning, rhinorrhea, piloerection, abdominal cramps). She reports using heroin intravenously daily and has had no prenatal care. She is homeless and has no insurance. She is tearful and says she wants to stop using but doesn’t know how. She has track marks and mild cellulitis at an injection site. Fetal heart tones are normal. The ED is in a rural area with no buprenorphine-prescribing providers nearby, and the nearest methadone clinic is 2 hours away. The hospital has a policy against initiating buprenorphine in the ED.
1. What are the immediate priorities for this patient’s care?
Read the worked answer
Address withdrawal and prevent complications: initiate treatment for opioid use disorder (OUD) with an evidence-based medication (buprenorphine or methadone). Given the hospital policy, advocate for an exception or transfer to a facility where buprenorphine can be initiated. If not possible, arrange urgent referral to a methadone clinic, but transportation is a barrier. Provide supportive care for withdrawal symptoms (e.g., antiemetics, clonidine with caution due to fetal risk, but better to use opioid agonist). Treat cellulitis with antibiotics. Perform a comprehensive assessment including infectious disease screening (HIV, hepatitis B and C, syphilis), STI testing, and ultrasound for fetal well-being. Connect with social work for housing, insurance, and transportation. Involve obstetrics for prenatal care. Educate about risks of untreated OUD in pregnancy (preterm birth, low birth weight, neonatal abstinence syndrome).
2. How would you address the hospital’s policy against initiating buprenorphine in the ED?
Read the worked answer
Advocate for the patient by discussing the evidence with ED leadership: buprenorphine initiation in the ED is safe and effective and improves engagement in treatment. Cite guidelines from ACOG, SAMHSA, and ASAM supporting medication for OUD in pregnancy. Propose a protocol for ED-initiation with linkage to outpatient care. If the policy cannot be changed in time, arrange transfer to a hospital with capacity to initiate buprenorphine or methadone. Alternatively, coordinate with the nearest methadone clinic for urgent intake and provide transportation vouchers. Document the barriers and the patient’s desire for treatment. Involve a patient navigator or social worker to facilitate. If necessary, contact the state’s perinatal addiction hotline for assistance.
3. What are the key considerations for the fetus and neonate?
Read the worked answer
Untreated OUD in pregnancy increases risks of preterm birth, low birth weight, placental abruption, and fetal death. Treatment with methadone or buprenorphine improves outcomes. Buprenorphine is associated with less severe neonatal abstinence syndrome (NAS) compared to methadone. The neonate should be monitored for NAS after delivery. Encourage breastfeeding if the mother is stable on medication. Coordinate with pediatricians for NAS assessment using a standardized tool. Provide contraception counseling postpartum and support for parenting. Ensure the mother has stable housing and continued OUD treatment postpartum to prevent relapse.