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Perinatal SUD Education Series

Mother-Infant Dyad & Integrated Perinatal SUD Care

Outcomes, Ethics, and Systems

Clinical Guide for Psychiatry and Obstetrics

Disclosure: This presentation discusses off-label medication use in pregnancy. Clinical decisions should be individualized.
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Session Framework

Learning Objectives

👤

Patient Care

  • Define the minimum effective dyad-care package
  • Implement universal screening protocols
  • Coordinate MOUD through pregnancy and postpartum
🏥

Systems Practice

  • Compare integrated care models
  • Apply AIM bundle 5 R's framework
  • Design warm handoff protocols
⚖️

Ethics & Communication

  • Navigate consent for testing
  • Balance CPS reporting requirements
  • Practice non-stigmatizing communication
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Epidemiology

The Perinatal SUD Crisis

1,249
Pregnancy-associated overdose deaths
(2017-2020)
81%
Increase in overdose deaths
(2017-2020)
75%
Maternal drug-related deaths
occur postpartum
84%
Pregnancy-related deaths
deemed preventable
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Clinical Problem

Why Integration Matters

Traditional Siloed Care

  • Women avoid prenatal care due to fear of CPS
  • Missed behavioral health needs
  • Fragmented communication
  • Polypharmacy risks
  • Conflicting advice (e.g., breastfeeding)
  • "Fourth trimester" cliff

Integrated Care

  • Preterm birth reduced by 55%
  • Shorter hospital stays
  • Reduced NICU admissions
  • 69% MOUD continuation at 6 months
  • Warm handoffs built in
  • Trauma-informed approach
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Core Principles

The Dyad-Care Package

1
Universal Screening
→
2
MOUD Continuity
→
3
Neonatal Care
→
4
Mental Health
→
5
Family Plan
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Screening & Assessment

Validated Screening Tools

Tool Purpose Timing
4P's Plus / 5P's Substances + IPV/Depression First visit, each trimester
NIDA Quick Screen Substance use severity First visit
EPDS Perinatal depression Each trimester + PP weeks
PC-PTSD-5 Trauma history First visit
Key Point: Toxicology requires informed consent—biological testing should not replace verbal screening.
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Pharmacotherapy

MOUD Continuity Through Pregnancy

Phase Key Actions
Prenatal Initiate MOUD ASAP; earlier predicts postpartum continuation. Consider split dosing in 3rd trimester (increased metabolism).
Intrapartum Continue baseline MOUD—does NOT provide analgesia. Avoid partial agonist-antagonists (butorphanol, nalbuphine).
Postpartum Reassess dose (metabolism normalizes). Plan for 12-month minimum MOUD continuation.
Evidence: Withdrawal/detox associated with 59-90% relapse rates. MOUD is the gold standard.
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Neonatal Care

NOWS Management: Eat, Sleep, Console

6.7
Days earlier discharge
with ESC approach
63%
Reduction in
pharmacotherapy need

Key ESC Components

  • Rooming-in (avoid routine NICU admission)
  • Breastfeeding strongly recommended if stable on MOUD
  • Function-based assessment vs. Finnegan scoring
  • Parental involvement in non-pharmacologic care
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Care Delivery

Comparing Care Models

Model MOUD Retention Ideal For
Integrated OB-SUD Clinic 69% at 6 months Stable housing; medical home
Residential Program High during treatment Unstable housing; CPS involvement
Postpartum Transition Prevents postpartum gaps All patients; highest-risk period
Home-Visiting/Peer Facilitates linkage Underserved populations
Synthesis: Layered, step-wise care—integrated OB-SUD clinic as medical home, supplemented by residential when indicated, robust postpartum transition, and community peer supports.
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Interactive Case

Case 1 — Jane

Clinical Scenario

28-year-old G2P1 at 24 weeks with opioid use disorder, currently on buprenorphine 16 mg daily. Enters prenatal care late, fearing judgment because in her last pregnancy her newborn went to foster care after positive opioid screen.

What is your first priority in engaging Jane?

Teaching Point: The therapeutic alliance is paramount. Acknowledge her fear, demonstrate transparency about consent for testing, and explicitly state the goal is to keep her and baby together.

Key Actions:

  • Obtain consent for any toxicology
  • Review Plan of Safe Care requirements transparently
  • Connect with peer recovery specialist
  • Document strengths and engagement, not just risks
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Ethics & Legal

Navigating Ethics

Non-Punitive Documentation

  • Use person-first language
  • Avoid "addict," "dirty urine"
  • Include strengths and progress
  • Document consent for testing

Consent for Testing

  • Supreme Court 2001: No testing without consent for reporting
  • Preferred: verbal screening first
  • Explain implications transparently
  • Keep results confidential
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Implementation

The AIM 5 R's Framework

1
Readiness
→
2
Recognition
→
3
Response
→
4
Reporting
→
5
Respectful Care

Missouri PQC demonstrated 47.9% increase in screening rates, 144.4% increase in maternal safe plans of care

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Clinical Algorithm

Consultation Algorithm

1
Prenatal ID
→
2
Warm Handoff
→
3
MOUD Initiation
→
4
Delivery
→
5
Postpartum
Key Transitions: Every handoff requires: (1) Direct provider communication, (2) Appointment scheduled before discharge, (3) Medication supply secured, (4) Plan of Safe Care reviewed
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Knowledge Check

Test Yourself

Which of the following is TRUE regarding the Eat, Sleep, Console (ESC) approach?
A It requires more pharmacotherapy than traditional Finnegan scoring
B It reduces hospital stay by 6.7 days and pharmacotherapy by 63%
C It recommends routine NICU admission for monitoring
D It discourages breastfeeding for mothers on MOUD

Correct! The ESC-NOW trial demonstrated that infants cared for with ESC were medically ready for discharge 6.7 days earlier and 63% less likely to receive pharmacotherapy. ESC emphasizes rooming-in and breastfeeding support.

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Summary

10 Key Teaching Points

  1. Screen universally with validated tools
  2. Initiate MOUD early; continue through 12 months postpartum
  3. Coordinate peripartum pain (multimodal)
  4. Monitor neonates with ESC approach
  5. Integrate postpartum mental health screening
  6. Complete Plans of Safe Care collaboratively
  7. Execute warm handoffs at every transition
  8. Layer peer and community supports
  9. Practice harm reduction (no discharge for relapse)
  10. Address bias systematically
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Health Equity

Addressing Disparities

Equity Dimension Disparity Intervention
Race/Ethnicity Black women receive MOUD at 31% vs 57% White Standardized protocols; cultural competency
Insurance 28.7% experience coverage disruption 12-month Medicaid extension
Rurality Fewer buprenorphine prescribers Tele-MOUD; mobile units
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Resources

Key Frameworks & Tools

National Guidelines

  • SAMHSA Clinical Guidance (SMA 18-5054)
  • AIM CPPPSUD Patient Safety Bundle
  • ACOG Committee Opinion
  • AAP Policy Statement
  • SOAP Consensus Statement

Clinical Tools

  • 4P's Plus Screening Tool
  • EPDS Depression Scale
  • Eat, Sleep, Console Protocol
  • Plan of Safe Care Template
  • Warm Handoff Checklist
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Conclusion

Thank You

"The integrated, family-centered approach—whether delivered outpatient, inpatient, or at home—yields better maternal engagement, reduced substance use, improved infant health, and increased mother-baby bonding."

Questions?

See the companion Speaker Notes and Deep Dive materials for additional cases and resources.