Pregnancy and substance use — structured clinical viva

This is a stabilisation and counselling viva, not a detox-on-demand request. Near-miss overdose plus moderate withdrawal (COWS ~15) makes her a candidate for buprenorphine induction now if timing of last full agonist supports it, or for specialist methadone induction if preferred — not cold-turkey cessation at 32 weeks.^[3][4][6]

Buprenorphine vs methadone. MOTHER and Suarez support that buprenorphine may associate with more favourable neonatal NAS/preterm/growth metrics than methadone for some outcomes, but maternal retention, prior response, and logistics matter; neither is “banned.” Shared decision-making with obstetric–addiction team.^[1][2]

“Born addicted forever.” Correct the myth: neonates may show time-limited withdrawal (NAS/NOWS) that is treated supportively ± short-course neonatal opioids — this is not lifelong “addiction” in the adult OUD sense. OAT during pregnancy is medical treatment that reduces unregulated use risk.^[1][4]

Alcohol. Weekend heavy drinking still warrants abstinence counselling for the remaining pregnancy (no known safe level; FASD risk).^[5]

Breastfeeding. If stable on OAT without ongoing illicit use, breastfeeding is often encouraged and may mitigate NAS severity — individualise with neonatal team; heavy ongoing alcohol/illicit use changes the advice.^[4][6]

Postpartum. Highest practical risk window for relapse and overdose — continue OAT, naloxone kit, early review, mood screen, contraception.^[4][6]