Leech 2025: costs and outcomes of opioid treatments in pregnancy

What they tested

This was not a study of real patients. The researchers built a simulation model of hypothetical pregnant people with opioid use disorder who started treatment during pregnancy, following the parent through pregnancy and after birth and the baby through the first year and over a lifetime.

It compared outpatient methadone, buprenorphine and buprenorphine-naloxone; methadone, buprenorphine or naltrexone after withdrawal managed in hospital; and hospital-managed withdrawal with or without intensive behavioural treatment. Outcomes included return to illicit use, overdose, preterm birth, low birth weight, newborn opioid withdrawal, infant death, costs and quality-adjusted life-years (QALYs), a measure that combines length and quality of life.

What they found

Over pregnancy and the postpartum period, buprenorphine dominated all other strategies, meaning it gave more benefit for less cost, though methadone was a viable alternative.

Once infant outcomes over a lifetime were added, buprenorphine gained 0.262 QALYs per person compared with methadone and saved an average of $21,512 per person.

Compared with naltrexone, buprenorphine gained 0.228 to 0.229 QALYs per person. Average savings were $25,316 per person against oral naltrexone and $46,437 against extended-release naltrexone.

The authors concluded that methadone and buprenorphine both remain viable options in pregnancy, with buprenorphine offering the greatest benefit once infant outcomes are counted.

Limits

• It's a simulation of hypothetical patients, so the results depend on the assumptions and data put into the model.
• The main analysis assumed treatment started during pregnancy, with naltrexone only after withdrawal in hospital. A separate scenario looked at people already stable on treatment before pregnancy, but the abstract doesn't give its naltrexone results.

What it means if you're considering naltrexone

For pregnant people with opioid use disorder, this model favours buprenorphine over naltrexone. It doesn't cover naltrexone for alcohol use disorder in pregnancy, and it says little about someone already stable on naltrexone before becoming pregnant.