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  • Writer's pictureDr. Harold Pierre

Low-Dose Buprenorphine Induction for Pregnant Women with Fentanyl Addiction

Updated: Dec 7, 2023

The opioid epidemic has devastated families across the United States. And pregnant women with opioid use disorder (OUD) face extra risks to their health and pregnancies. However, medication-assisted treatment (MAT) with medications like buprenorphine has given many expecting mothers a lifeline to recovery. A recent medical study highlighted how careful approaches using low-dose buprenorphine induction can further help pregnant women start MAT while avoiding painful withdrawal. As an experienced addiction medicine physician, I wanted to spotlight their findings and process to help other providers offer this potentially life-saving option.


Overview of the University of Maryland's Low-Dose Buprenorphine Study


Researchers at the University of Maryland School of Medicine published their study on low-dose buprenorphine induction in the Journal of Addiction Medicine in 2023.

Their goal was to evaluate the effectiveness of a gradual, small-dose induction protocol for pregnant women dependent on opioids like heroin or fentanyl. Rapid induction of buprenorphine can trigger sudden withdrawal if women still have other opioids in their systems. This low-dose approach aimed to avoid those negative effects.


The researchers conducted a case series, following 6 pregnant patients starting low-dose buprenorphine over a nearly 2-year period. The women ranged from 9 to 36 weeks gestation, and most had fentanyl as their primary opioid of use.


By starting with micro-doses of buprenorphine and slowly titrating up, the majority of women completed induction without withdrawal issues. Two continued taking buprenorphine through delivery.


These real-world findings suggest low-dose induction protocols could provide a comfortable and effective option for pregnant women to begin medication-assisted treatment.


Step-By-Step: How The Low-Dose Buprenorphine Induction Process Works


The University of Maryland study utilized a straightforward low-dose buprenorphine induction regimen. Here is an overview of how it works:


Outpatient Induction (4 patients received the following):


  • Day 1: 1/4 of 2mg strip sublingual buprenorphine/naloxone every 6 hours (total of 4 doses)

  • Day 2: 1/2 of 2mg strip sublingual buprenorphine/naloxone every 6 hours (total of 4 doses)

  • Day 3: Full 2mg strip sublingual buprenorphine/naloxone every 6 hours (total of 4 doses)

  • Day 4: Stop illicit opioid use and start maintenance dose of 8mg buprenorphine sublingual twice daily


Supportive medications like ondansetron, clonidine and hydroxyzine can also be prescribed as needed.


Inpatient Induction:


  • Give 1 dose IV hydromorphone for initial withdrawal relief.

  • Prescribe 5mg oxycodone every 4 hours until the last day.

  • On the final day, switch to the sublingual buprenorphine dosing approach determined by their doctor.


This gradual schedule allows the partial agonist buprenorphine to slowly build up in the body while tapering down full agonists. The tiny starting doses help avoid precipitating acute withdrawal.


Real-World Outcomes: Completion Rates and Impact on Opioid Use

In the University of Maryland study, 83% of the pregnant women completed at least one low-dose induction successfully. None experienced precipitated withdrawal based on self-reports.


  • 33% continued taking buprenorphine through delivery.

  • One participant abstained from illicit opioids entirely after induction.

  • The others reported returning to use by the time of delivery - highlighting how this treatment is just the initial step in lifelong recovery.


However, the high completion rates are promising. Low-dose buprenorphine induction was both feasible and well-tolerated for this vulnerable population. Larger comparison studies could further investigate outcomes versus traditional induction approaches.


Integrating Low-Dose Buprenorphine Inductions into Prenatal Addiction Care


Happy pregnant woman making heart gesture at home copy

For providers serving pregnant women with opioid use disorders (OUD), low-dose buprenorphine induction offers a promising option to start MAT gently. Based on these early findings, I recommend considering incorporating this approach, both in outpatient and inpatient settings.


Here are some benefits this technique may provide:


  • Increased comfort - Gradual dosing avoids distressing acute withdrawal. This can lead to higher rates of induction completion.

  • Accessibility - The outpatient protocol uses affordable, widely available 2mg buprenorphine/naloxone films.

  • Short duration - The entire low-dose induction takes only 4 days until reaching a maintenance dose.

  • Flexibility - Dosing can be adjusted based on individual patient needs and responses.


However, some limitations to note include:


  • Continued illicit opioid use - Some women continued using opioids like heroin or fentanyl for the first few days until fully transitioned. Harm reduction education on safely using during this period is critical.

  • Stopping treatment - More research is needed on how to improve retention in MOUD after initial induction. Ongoing psychosocial support is key.

  • Knowledge gaps - Larger studies directly comparing low-dose to standard induction approaches would provide valuable data.


Overall, this low-dose induction technique shows significant promise for supporting pregnant women with OUD in starting potentially life-saving treatment. While not a cure-all, it could be an important first step toward recovery and improved maternal and child health outcomes. Integrating this protocol into prenatal addiction medicine programs can help reach more mothers in need.


Junn S, Tugarinov N, Mark K. Low-dose Induction of Buprenorphine in Pregnancy: A Case Series. J Addict Med. 2023;00(00):1-5. doi:10.1097/ADM.0000000000001233


If you or a loved one struggle with opioid addiction, help is available. Call the national SAMHSA helpline at 1-800-662-HELP (4357) or seek treatment resources from your local health department. Recovery takes work, but you do not have to walk the path alone.


About the author:

Dr. Harold Pierre is a board-certified anesthesiologist and addiction medicine specialist with over 20 years of experience. He is board-certified by the American Board of Anesthesiology and the American Board of Preventive Medicine.


This website is provided for educational and informational purposes only and does not constitute providing medical advice or professional services. The information provided should not be used for diagnosing or treating a health problem or disease, and those seeking personal medical advice should consult with a licensed physician or another qualified medical professional. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.




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