This section focuses on treatment of substance use disorders during lactation. A thorough review of these subjects can be found in ABM Protocol #21: Breastfeeding in the Setting of Substance Use and Substance Use Disorder (SUD).

For more detailed information and references on specific substances, please refer to LactMed, e-lactancia, Infant Risk, or Mother to Baby.

While acamprosate is likely to enter milk based on its  low molecular weight and lack of protein binding, it has low oral bioavailability per LactMed so it is unlikely to have systemic effects on the breastfed infant, other than diarrhea, for which the infant should be monitored¹ Lactating individuals should be engaged in shared decision making about the use of acamprosate, but there is no absolute indication to pump and dump.

Naltrexone is an opioid antagonist used in the management of opioid use disorder (OUD) and alcohol use disorder. While data on naltrexone use during lactation is limited, available data suggests a low relative infant dose (RID) and infant exposure would likely be minimal.¹ If the lactating parent needs naltrexone for management of alcohol use disorder or opioid use disorder (OUD), there is no absolute indication to pump and dump. For more information about naltrexone, please see the section on Pain Medications.

Disulfiram/Antabuse is a secondary treatment for alcohol use disorder and works by inhibiting alcohol dehydrogenase (ADH). There is no data on the use of disulfiram during lactation.¹ Drug labeling recommends not using disulfiram during lactation. Due to the lack of safety data and data on infant exposure as well as the unknown risks of prolonged ADH inhibition in the infant, the use of disulfiram is not recommended during lactation and alternatives preferred.

Gabapentin is used off-label for the management of alcohol use disorder. While the infant should be closely monitored for side effects (such as drowsiness and insufficient weight gain) with use of this medication during lactation, there is not an absolute indication to pump and dump and shared decision making should be used. For more information about gabapentin, please see the section on Pain Medications.

Nicotine replacement therapy (NRT) comes in many forms such as gum, lozenges, patches. NRT carries risks for similar side effects to tobacco use as described in the section on tobacco, although the overall exposure to nicotine is lower for the infant with NRT use than with smoking or vaping.¹ While infants should be monitored for side effects and complete cessation of nicotine use is preferable, NRT is preferable to ongoing use of other nicotine products. For more information, see the section on Tobacco.

Varenicline is a partial nicotine agonist. There is no data on the use of varenicline during lactation. There is a theoretical risk to lung development in the infant based on animal data as well as risks for vomiting and seizures if the infant is exposed to varenicline as described in LactMed.¹ Alternative medications are preferred due to the theoretical infant risks and the lack of safety data on the use of varenicline during lactation.

While breastfed infants should be monitored for side effects and lactating parents should be engaged in shared decision making if bupropion is needed, there is no absolute indication to pump and dump. For more detailed information on bupropion use during lactation, see the section on Perinatal Mood and Anxiety Disorders (PMADs). 

Methadone is an opioid agonist used in the management of opioid use disorder (OUD). For information on the use of methadone during lactation, please see the section on Pain Medications.

Buprenorphine is a partial opioid agonist used in the management of OUD. Limited data suggest low RID and low oral bioavailability.¹ While infants (particularly neonates and premature infants) should be monitored for possible side effects such as sedation, there is no absolute indication to pump and dump. For more information on the use of buprenorphine during lactation, please see the section on Pain Medications.

Naltrexone is an opioid antagonist used in the management of OUD and alcohol use disorder. While data on naltrexone use during lactation is limited, available data suggests a low relative infant dose (RID) and infant exposure would likely be minimal.¹ If the lactating parent needs naltrexone for management of alcohol use disorder or opioid use disorder (OUD), there is no absolute indication to pump and dump. For more information about naltrexone, please see the section on Pain Medications.