Feasibility of an Inpatient Split-Dose Rapid Methadone Induction Protocol for Pregnant Individuals

Opioid use disorder (OUD) is associated with adverse perinatal outcomes. Pregnant patients often require higher doses of methadone, including split-dosing, due to physiologic changes, and stabilization is critical. Little guidance exists for methadone titration in this population, and hospitalization offers a unique opportunity to rapidly initiate methadone. This report describes our experience with inpatient split-dose, rapid methadone induction among high-risk pregnancies at 1 tertiary care center.

We conducted a retrospective chart review of hospitalized pregnant individuals with OUD seen by our interprofessional addiction medicine consult service between June 2023 and July 2024. We included patients who were initiated on the rapid inpatient split dose methadone protocol, which includes dose recommendations (maximum 70 mg day 1, 80 mg day 2, 100 mg day 3, 120 mg day 4, and 140 mg day 5) and strict inclusion and exclusion criteria.

Fourteen unique pregnant patients received the protocol. Average total daily doses of methadone on days 1-5 were 57, 80, 85, 93, and 105 mg, respectively. The titration for one patient was slowed for asymptomatic bradycardia; otherwise, there were no adverse events. After discharge, 12 patients (86%) attended an opioid treatment program (OTP) intake, and 8 (57%) remained on methadone at 30 days postdischarge. Of patients who were discharged on split-dose methadone and followed up at an OTP, all were continued on split-dosing by the OTP.

Inpatient split dose, rapid methadone initiation for appropriately selected pregnant individuals is feasible. Posthospitalization OTP retention rates were comparable to the general population, highlighting the need for more support for this vulnerable population.