Opioid Agonist to Buprenorphine Cross-titration During Pregnancy: A Case Report

We present a case report of a first-trimester pregnant individual with chronic pain on chronic opioid therapy who successfully cross-titrated from full-μ agonist opioid to buprenorphine without causing significant withdrawal symptoms.

A 37-year-old gravida 1, para 0 woman with chronic pain on opioid therapy successfully completed a 6-week cross-titration from 120 morphine equivalent dose to buprenorphine in her first trimester without affecting pain scores, functional capacity, withdrawal symptoms except for mild nausea and insomnia, or adverse perinatal outcomes. After increasing her buprenorphine in the second trimester, at 38 weeks, she bore a healthy neonate without eliciting signs of neonatal abstinence syndrome while on a stable buprenorphine dose.

The American College of Obstetricians and Gynecologists and the American Society of Addiction Medicine agree that pregnant patients with chronic pain should avoid or minimize opioids. For patients on chronic opioid therapy unable to minimize opioid use during pregnancy, it is unclear whether to continue their chronic opioid therapy or transition to other medications, including buprenorphine. This case demonstrated how one pregnant person with chronic pain on opioid therapy but not meeting diagnostic criteria for opioid use disorder safely transitioned from full-μ agonist opioids to buprenorphine without precipitating withdrawal or adverse perinatal outcomes. Cross-titration could be similarly performed for a pregnant patient with untreated opioid use disorder. In addition, the used cross-titration schedule and the rationale are provided.