Successful Buprenorphine/Naloxone High-dose Induction in Pregnancy

Medication for opioid use disorder (OUD) with methadone or buprenorphine/naloxone is recommended for pregnant women with OUD. Traditional buprenorphine/naloxone induction requires patients to be in moderate withdrawal before the first dose of medication to minimize the chances of precipitated withdrawal. The high-dose buprenorphine “macroinduction” method was described in 2021 in response to increasing illicit drug supply potency, and involves giving larger doses of buprenorphine to patients for whom opioid withdrawal is undesirable. This method is described for the first time in a pregnant woman. A 31-year-old G2P1 woman at 22 weeks, with severe opioid and polysubstance use disorder, successfully started on buprenorphine/naloxone through a high-dose-induction protocol. The dose was started at 16 mg sublingual, titrating to opioid withdrawals measured by COWS every 2 hours. She did not experience precipitated withdrawal and was able to stop using nonprescribed opioids once at a therapeutic dose of buprenorphine/naloxone. The patient was maintained on this regimen, and also began receiving regular prenatal care at a high risk clinic. Four months later, she had an uncomplicated delivery without maternal or neonatal withdrawals. While first-line recommendations still remain to use traditional buprenorphine/naloxone induction when patients present in withdrawal, and obtaining informed consent regarding the lack of research on high-dose induction in pregnancy as well as discussion of risks and benefits is essential, this represents a novel way of initiation of medication for OUD. This method may enhance choice and collaboration between health care providers and women impacted by substance use in pregnancy.