ABSTRACT Background Rates of opioid use disorder and opioid overdose during pregnancy and in the postpartum period are increasing. While methadone remains a cornerstone of treatment for women with opioid use disorder during pregnancy, methadone titrations are constrained by guidelines designed for the outpatient setting, where it may take several weeks before doses are therapeutic. Case Summary In the current case report, we describe and discuss a rapid inpatient titration of methadone in an acute care setting for a pregnant woman with severe opioid use disorder, not previously on medication for opioid use disorder. Discussion Pregnant women with severe opioid use disorder are at high risk of negative maternal and fetal outcomes, necessitating a mechanism for rapid stabilization on evidence-based pharmacotherapy. While current methadone guidelines are designed to minimize overdose risk during the titration period in outpatient settings, we believe this risk can be mitigated in the inpatient setting by utilizing small, split doses and careful observation.