Pregnancy and substance use — OAT, alcohol, NAS, and non-punitive care (MEQ)

(i) Assessment and non-punitive framing. See her alone for part of the visit (IPV safety). Use universal SBIRT-style verbal screening, validate courage in disclosure, and explain that the goal is health for her and the baby — not punishment. Inventory opioids, alcohol, methamphetamine, tobacco: amounts, routes, last use, overdoses, prior OAT, BBV risk, mental health, suicide, housing. Be transparent about mandatory reporting thresholds without weaponising them to force urine tests. Offer toxicology only with consent for clinical planning. Baseline labs (FBC, U&E, LFT, BBV, STI), dating/growth ultrasound pathway, ECG if methadone planned.[5][6][3]

(ii) Substance-specific priorities. Alcohol: counsel complete abstinence (no known safe level; FASD prevention); assess withdrawal risk; thiamine if dependent/malnourished; medically supervised withdrawal if needed; avoid disulfiram.[4] Opioids: recommend OAT with methadone or buprenorphine rather than forced detox; induct/maintain under specialist protocols (methadone start low/go slow, often day-1 range ~10–30 mg oral in tolerant adults with careful review; buprenorphine after adequate withdrawal, maintenance often 8–24 mg SL); obstetric–addiction liaison.[2][3][7] Stimulants: no agonist OAT; MI/contingency management/CBT, residential options if needed, growth and abruption vigilance.[6] Tobacco: behavioural cessation support; consider NRT if behavioural care alone insufficient.[5] Integrated schedule beats multiple disconnected referrals.

(iii) NAS counselling. Explain that babies exposed to opioids (including therapeutic OAT) may show neonatal abstinence/withdrawal — irritable, feeding difficulty, autonomic signs — usually manageable with supportive care and sometimes short neonatal morphine protocols. NAS is expected and treatable, not proof she is a bad mother or that OAT failed. MOTHER-era data can inform methadone vs buprenorphine neonatal trade-offs without forcing switches if she is stable.[1][2][6]

(iv) IPV, safeguarding, postpartum. Document IPV; safety plan; offer confidential resources; do not force disclosure in front of partner. Child protection: collaborative safety planning based on capacity to care, engagement, and supports — not automatic removal for OAT or treatable NAS. Postpartum plan before discharge: continue OAT, take-home naloxone, early addiction and maternity review, mood/psychosis screen, contraception, housing supports — highest relapse/overdose window after birth.[6][7]