Written by Elizabeth Cairns, Mobilize Recovery Special Projects and Michael Masiowski, MD, reviewed by Code Recover Clinician Advisors, August 2026

Drug overdose is now among the leading causes of pregnancy-associated death in the United States, and overdose mortality among pregnant and postpartum people rose roughly 81% between 2017 and 2020 — with more than one in six pregnancy-associated deaths that year involving an overdose. (source) Perinatal Substance Use Disorder (PSUD) refers to substance use occurring during pregnancy and through the first year postpartum.

Unlike many patients with OUD, pregnant patients are usually in contact with the health system, but contact is not the same as treatment. Pregnant people with OUD initiate prenatal care later and attend less consistently than other pregnant patients. They use emergency services at higher rates, yet fewer than half receive medication for their opioid use disorder. (source) When they are seen in the ED, it is rarely their only recent clinical contact, but it is often one where the opportunity to begin treatment is missed.

The errors most commonly made in these encounters are errors of omission: withholding buprenorphine out of uncertainty about fetal safety, deferring the decision to obstetrics, or discharging a patient without treatment because the case feels outside the department's scope. Each of these is more dangerous than acting. The clinical guidance is clear and definitive:

Medication is the standard of care in pregnancy

Buprenorphine and methadone are recommended treatments for OUD during pregnancy and are safe during breastfeeding. ACOG is explicit that opioid agonist pharmacotherapy is preferable to medically supervised withdrawal, because withdrawal carries relapse rates ranging from 59% to more than 90% and poorer outcomes. Relapse in pregnancy brings loss of tolerance and accidental overdose, communicable disease transmission, obstetric complications, and loss of prenatal care. (source)

Pushing a patient into detoxification rather than offering MOUD may seem like the conservative choice, but it actually puts the patient at risk.

The ED does not need to defer this decision

Buprenorphine can be started in the ED for a pregnant patient using the same protocol used for any other patient. Neither hospital admission nor fetal monitoring is required to initiate buprenorphine, regardless of gestational age. (source) Consultation with obstetrics is appropriate and useful, but waiting for it is not a reason to discharge a patient in withdrawal without treatment.

Two practical notes:

• Dosing may need to change across pregnancy. Increased metabolism and volume of distribution in the second and third trimesters mean a previously stable dose may become inadequate; split dosing is sometimes used. Coordinate adjustments with the patient's OB or opioid treatment program rather than assuming the prior dose still fits. (source)
• Methadone follows the same rules as elsewhere. It cannot be started in the ED for long-term treatment, but the federal three-day rule applies here as it does for any patient — an ED clinician can dispense up to a three-day supply to relieve acute withdrawal while arranging OTP intake.

Overdose reversal and take-home naloxone

A pregnant patient in overdose should receive naloxone as any other patient would. ACOG is unambiguous: although induced withdrawal may contribute to fetal stress, naloxone should be used in a pregnant patient in the case of maternal overdose in order to save her life. (source) Naloxone is the standard treatment for opioid overdose regardless of pregnancy status. (source) Take-home naloxone should be provided at discharge to the patient and, where appropriate, to family or partners — and this applies with equal force to postpartum patients, for the reasons below.

Neonatal Opioid Withdrawal Syndrome is not a reason to withhold treatment

NOWS is a recognized, expected, and treatable consequence of maternal MOUD, and its occurrence is independent of maternal dose — lowering or withholding medication does not prevent it. Rooming-in and breastfeeding have been shown to reduce NOWS severity and neonatal length of stay. (source) Untreated maternal OUD carries far greater risk to both patient and infant than a managed, anticipated neonatal withdrawal.

Drug testing, consent, and documentation

A positive urine drug test does not diagnose a substance use disorder, and testing requires the patient's consent. A UDT is not required to initiate treatment when the clinical presentation and history are consistent with opioid tolerance and withdrawal. (source)

Documentation in these encounters carries downstream consequences that documentation in most ED encounters does not — it may be read by child welfare agencies, courts, and future clinicians. Record clinical findings, not moral characterizations.

Reporting and Plans of Safe Care

Federal law (CAPTA) requires states to have plans of safe care in place for infants affected by prenatal substance exposure, but notification and reporting requirements vary substantially by state, and hospital policy varies further. (source) Know your state's requirements and your institution's protocol before the encounter, not during it.

What clinicians can do universally is correct the misunderstanding: a Plan of Safe Care is a coordinated support plan focused on the health and safety of parent and infant. It is not, in itself, a child removal action. Fear of losing custody is the single most powerful driver of care avoidance in this population — patients delay presenting, decline treatment, and leave against medical advice because of it. Explaining accurately and without hedging what will and will not happen next is not a social nicety here; it is clinical care that keeps a patient engaged.

The postpartum window is the highest-risk period

Overdose risk in this population peaks 7–12 months after delivery. In a Massachusetts cohort, the overdose rate during that window was nearly four times what it was in the third trimester. (source) That peak arrives well after standard postpartum care has ended and, in many states, after pregnancy-related Medicaid coverage has lapsed. A postpartum patient presenting to the ED is not past the danger; she is arriving in the middle of it. Treat a postpartum presentation with the same urgency as a pregnancy presentation, and do not assume follow-up care is still in place.

Where peers fit

Fear, not ambivalence, is what drives most of the difficult behavior in these encounters. A peer navigator with lived experience can name that fear, explain what happens next in language the patient can absorb, and stay with her through a period when the clinical team is necessarily moving between other patients. For this population in particular, the peer is often the reason the patient is still in the department when the treatment decision gets made.