Number of buprenorphine induction attempts impacts maternal and neonatal outcomes: a multicenter cohort study

Jeannie C. Kelly, Nina K. Ayala, Lauren Holroyd, Nandini Raghuraman, Ebony B. Carter, Samantha A. Williams, Melissa M. Mills, Hayley Friedman, Fan Zhang, Courtney Townsel

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BACKGROUND: Buprenorphine can be used to treat maternal opioid use disorder effectively and decrease obstetrical risks. Compared with the use of other medications to treat opioid use disorder, the use of buprenorphine results in improved neonatal outcomes; however, its use is associated with higher rates of treatment attrition. Initiation of buprenorphine, termed “induction,” is a high-risk time for treatment dropout and can require repeated attempts. OBJECTIVE: This study aimed to evaluate the effect of multiple buprenorphine induction attempts on maternal and neonatal outcomes. STUDY DESIGN: This was a retrospective cohort study of all pregnant patients who underwent sublingual buprenorphine induction for the treatment of opioid use disorder from June 18, 2018, to January 1, 2021, at 3 tertiary care centers. Patients who required only 1 attempt for successful buprenorphine induction were compared with those who required multiple attempts but ultimately were successful in the treatment initiation during pregnancy, confirmed by urine drug screening. The primary outcome was nonprescribed opioid use at the time of delivery. The secondary outcomes included obstetrical and neonatal outcomes associated with opioid use disorder. Background characteristics were compared using Fisher exact, chi-square, Mann-Whitney U, and Student t tests. The outcomes were compared using multivariable logistic regression, and time to delivery after initiation of prenatal care was compared between groups using Kaplan-Meier curves and a Cox proportional-hazards model. RESULTS: Overall, 63 patients undergoing buprenorphine induction during pregnancy were included, with 38 (60.3%) patients with 1 attempt and 25 patients (39.7%) with multiple attempts. There was no statistical difference between the 2 groups in terms of background characteristics. Compared with a single successful attempt, multiple attempts at buprenorphine induction were associated with a significantly increased odds of nonprescribed opioid use at the time of delivery (76.0% vs 15.8%; adjusted odds ratio, 30.00; 95% confidence interval, 5.50–163.90), increased risk of preterm birth (48.0% vs 15.8%; adjusted hazard ratio, 3.24; 95% confidence interval, 1.17–8.95), and decreased rate of breastfeeding at both maternal discharge (24.0% vs 78.9%; adjusted odds ratio, 0.06; 95% confidence interval, 0.00–0.30) and infant discharge (24.0% vs 55.3%; adjusted odds ratio, 0.23; 95% confidence interval, 0.10–0.80). CONCLUSION: Requiring multiple attempts for buprenorphine induction significantly increases the odds of nonprescribed opioid use at the time of delivery and preterm birth and decreases the odds of breastfeeding. As the buprenorphine induction process may affect obstetrical outcomes for patients induced during pregnancy, investigating the techniques that increase the likelihood of successful induction is crucially needed to improve outcomes in patients with maternal opioid use disorder.

Original languageEnglish
Article number100998
JournalAmerican journal of obstetrics & gynecology MFM
Issue number7
StatePublished - Jul 2023


  • buprenorphine induction
  • opioid use disorder in pregnancy


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