Enrichment Materials

MOTHER Study: Landmark RCT

Jones HE, et al. "Neonatal Abstinence Syndrome after Methadone or Buprenorphine Exposure." N Engl J Med. 2010;363(24):2320-2331.

Randomized controlled trial comparing methadone vs. buprenorphine in pregnancy. Key finding: Buprenorphine associated with less severe NOWS and shorter hospitalization. Retention slightly lower than methadone. Both medications acceptable for treatment.

ESC Model Implementation

Young LW, et al. "Implementing the Eat, Sleep, Console Model of Care." Hosp Pediatr. 2025;15(3):e108.

Scoping review of ESC implementation across 42 hospitals. Found 6-8 day reduction in NICU stay and 50% reduction in pharmacologic treatment for NOWS. Rooming-in and non-pharmacologic care emphasized.

Fourth Trimester Mortality

Schiff DM, et al. "Fatal and Nonfatal Overdose Among Pregnant and Postpartum Women in Massachusetts." JAMA Psychiatry. 2022;79(2):171-179.

Population-based cohort study demonstrating overdose mortality peaks 7-12 months postpartum. Loss of tolerance and insurance churn identified as key modifiable risk factors.

ASAM National Practice Guideline 2025 Update

American Society of Addiction Medicine. "National Practice Guideline for the Treatment of Opioid Use Disorder: 2025 Focused Update." J Addict Med. 2025;19(1):e1-e20.

Updated recommendations for perinatal OUD treatment including buprenorphine-naloxone combination safety data, split-dosing guidance, and ESC model endorsement.

Question 1: Pharmacokinetics

A 34-year-old pregnant patient at 36 weeks gestation has been stable on methadone 80mg daily for opioid use disorder. She presents reporting afternoon withdrawal symptoms that resolve after her evening dose. Which of the following is the most appropriate management?

Options:

1. Increase morning dose by 20mg
2. Split total daily dose to BID administration
3. Switch to buprenorphine
4. Add clonidine for breakthrough symptoms

Correct Answer: 2 — Split to BID dosing. Third trimester progesterone induces CYP3A4 and increases volume of distribution, causing rapid metabolism and "trough" withdrawal. Splitting addresses pharmacokinetic issue better than increasing total dose.

Question 2: NOWS Assessment

A newborn delivered to a mother on buprenorphine is being assessed for neonatal opioid withdrawal syndrome using the "Eat, Sleep, Console" model. The infant can take 30ml feeds, sleeps 2-hour stretches, and can be consoled within 5 minutes when fussy. What is the most appropriate management?

1. Begin morphine 0.5mg/kg per Finnegan scoring
2. Continue rooming-in with non-pharmacologic care
3. Transfer to NICU for observation
4. Order Finnegan scoring q4h to monitor for change

Correct Answer: 2 — ESC functional assessment shows baby meeting all criteria (eating, sleeping, consolable). No pharmacologic treatment indicated. Finnegan scoring no longer recommended as primary assessment.

Question 3: Legal Framework

A pregnant patient on prescribed methadone for OUD delivers a healthy infant. The hospital social worker is unsure whether to file a report. Under federal law (CAPTA), which statement is correct?

1. All infants with prenatal substance exposure must be reported to CPS
2. Methadone exposure alone constitutes child abuse
3. A "Plan of Safe Care" must be developed for affected infants
4. Maternal consent is required for any notification

Correct Answer: 3 — CAPTA requires Plans of Safe Care for substance-exposed infants. This is distinct from CPS reporting of abuse. Being on prescribed MOUD is treatment, not abuse.