Substance use in pregnancy — structured SAQ (15 marks)

(a) Screening and initial assessment, and the governing stance (3 marks)

One mark for the stance, one for the validated tools, one for the broader assessment. ^[1][15]

• Stance — non-judgemental, trauma-informed, universal. Frame substance use as a treatable health condition, never a moral failing. Assure confidentiality within the limits of safety. A woman who fears judgment or child removal will minimise or lie and you will miss the window. ^[1][15]
• Validated screening tools. AUDIT-C for alcohol (positive at 3 or above, some authorities 2 for women); the 4Ps Plus for substances (Parents, Partner, Past, Present plus cigarette smoking). Both validated in pregnancy, under a minute, outperform clinical suspicion. ^[14][15]
• Broader assessment. Quantity, frequency, route, last use, withdrawal attempts; mental health (EPDS), intimate partner violence, blood-borne viruses (she is hepatitis C positive — confirm HIV, hepatitis B), housing, nutrition, and the social context that will determine whether any pharmacotherapy succeeds. ^[1]

(b) Pharmacological management of opioid use disorder (4 marks)

One mark for the principle, one for methadone, one for buprenorphine, one for the explicit non-detox rule. ^[1][3]

• Principle: opioid agonist therapy is first-line; detox in pregnancy is rarely indicated. The risks of supervised withdrawal are relapse, fetal distress and fetal demise. Maintenance stabilises the woman, engages her with care, and is the standard of care. ^[1][3]
• Methadone — full mu-opioid agonist, 60 to 120 mg orally daily, titrated to no withdrawal, no craving, no euphoria; once-daily dosing under supervised consumption. ^[1][3]
• Buprenorphine — partial mu-opioid agonist, 8 to 24 mg sublingually daily (the mono-product in pregnancy, not combined with naloxone). Start only once she is in mild withdrawal (Clinical Opiate Withdrawal Score 8 or above) to avoid precipitated withdrawal. ^[1]
• Do not detox against agonist therapy. If she insists, refer to specialist addiction medicine — supervised withdrawal is reserved for the highly selected, well-supported woman. ^[1]

(c) Methadone or buprenorphine — the trial evidence (4 marks)

One mark each for the trial identity, the neonatal morphine/stay result, the discontinuation trade-off, and the Cochrane context. ^[2]

• The MOTHER trial (Jones, NEJM 2010): 175 opioid-dependent pregnant women randomised to methadone versus buprenorphine across eight sites. ^[2]
• Neonatal outcomes favoured buprenorphine: buprenorphine-exposed neonates needed significantly less morphine (mean 1.1 mg versus 10.4 mg; P=0.0091), had a shorter hospital stay (10.0 versus 17.5 days; P=0.0091) and a shorter duration of NAS treatment (4.1 versus 9.9 days; P=0.003125). ^[2]
• The trade-off: more women in the buprenorphine arm discontinued treatment (33% versus 18%), partly because of dissatisfaction and precipitated withdrawal at induction. Maternal outcomes were otherwise comparable. ^[2]
• Cochrane (Minozzi 2020) context: three trials; birth weight may be higher with buprenorphine; rates of NAS treatment were similar in pooled analysis; quality of evidence low. Neither agent is clearly superior overall — the choice is individualised. ^[3]

(d) Plan for the neonate and the immediate postpartum period (4 marks)

One mark each for the four components. ^[1][16]

• Anticipate NAS; plan the birth in a unit with neonatal expertise. Onset 24 to 72 hours for methadone, 12 to 48 hours for buprenorphine. Use rooming-in, breastfeeding if stable, and non-pharmacological care first (the Eat Sleep Console model); reserve morphine or methadone for infants who are not eating, not sleeping, not consoling. Treat the infant, not the score. ^[4][16]
• Breastfeeding is encouraged if she is stable on her prescribed agonist with no illicit use — it reduces NAS pharmacotherapy need and stabilises the dyad. ^[16]
• Postpartum overdose prevention: the postpartum period is when women with OUD die. Prescribe take-home naloxone, book a postnatal review within the first week, and warm-handover to addiction medicine and the GP. Tolerance falls overnight and the structure of pregnancy falls away. ^[1]
• Contraception and relapse prevention: place a long-acting reversible contraceptive before discharge; address the tobacco and cannabis use in parallel; engage child protection where mandated without stigmatising the care. ^[1]