Mother-Infant Dyad & Integrated Perinatal SUD Care

Speaker Companion — Slide-by-Slide Notes & Anticipated Q&A

⏱️ Duration: 60 minutes | Audience: Psychiatry, OB, Peds, Social Work

Learning Objectives Review

By the end of this session, learners should be able to:

  1. Patient Care: Define the minimum effective dyad-care package and implement universal screening protocols
  2. Systems Practice: Compare integrated care models and apply AIM bundle 5 R's framework
  3. Ethics & Communication: Navigate consent for testing and balance CPS reporting requirements

Session Timing Breakdown

Segment Slides Time Method
Introduction & Objectives1-25 minPresentation
Epidemiology & The Crisis3-48 minPresentation
Core Principles5-915 minPresentation
Interactive Case108 minDiscussion
Ethics & Implementation11-1310 minPresentation
Knowledge Check145 minInteractive
Summary & Conclusion15-189 minPresentation

Slide-by-Slide Speaker Notes

Slide 1: Title Slide 2 min

📢 Key Talking Points

  • Welcome participants; acknowledge the interdisciplinary nature of this work
  • Emphasize that this is evidence-based clinical guidance, not legal advice
  • Preview that cases will anchor ethical discussions

💡 Speaker Tip

Take a quick poll: "How many of you have cared for a pregnant patient with OUD in the past month?" This gauges familiarity and sets the stage.

Slide 2: Learning Objectives 3 min

📢 Key Talking Points

  • Objectives span patient care, systems practice, and ethics
  • Emphasize that psychiatrists must be central architects, not peripheral consultants

🎯 Anticipated Question

Q: "Is this applicable to non-physician providers?"

A: Yes—nurse practitioners, social workers, and care coordinators play essential roles in the integrated team.

Slide 3: The Crisis (Epidemiology) 4 min

📢 Key Talking Points

  • 1,249 pregnancy-associated overdose deaths (2017-2020)
  • 81% increase in overdose deaths during this period
  • 75% of maternal drug-related deaths occur postpartum—this is the window we must address
  • 84% of deaths deemed preventable—this is our call to action

💡 Speaker Tip

Pause after "75% occur postpartum." This is often counterintuitive—participants may assume pregnancy itself is the highest-risk period. Emphasize that the fourth trimester is when we lose people.

Slide 4: Why Integration Matters 4 min

📢 Key Talking Points

  • Contrast traditional siloed care (fear-driven, fragmented) with integrated care (55% reduction in preterm birth)
  • Integrated models achieve 69% MOUD continuation at 6 months vs. national averages around 50%
  • "Fourth trimester cliff"—maternal care ends just as stress begins
Slide 5: The Dyad-Care Package 3 min

📢 Key Talking Points

  • Introduce the 5-pillar framework as the minimum effective standard
  • Note: This is NOT a "kitchen sink" approach—evidence shows mandated participation in all services can backfire
  • Low-barrier access with voluntary service utilization is the goal
Slide 6: Screening Tools 3 min

📢 Key Talking Points

  • 4P's/5P's screens for substances AND psychosocial risks
  • EPDS is critical—depression drives relapse
  • Toxicology requires consent per 2001 Supreme Court ruling

🎯 Anticipated Question

Q: "What if a patient refuses toxicology?"

A: Respect refusal—verbal screening is sufficient for clinical purposes. Do not let testing become a barrier to care.

Slide 7: MOUD Continuity 4 min

📢 Key Talking Points

  • Withdrawal/detox = 59-90% relapse—do NOT offer this in pregnancy
  • Split dosing in 3rd trimester due to increased metabolism
  • Avoid butorphanol/nalbuphine in labor—precipitates withdrawal
  • 12-month MOUD continuation is the minimum standard
Slide 8: NOWS Management (ESC) 4 min

📢 Key Talking Points

  • ESC = Eat, Sleep, Console (function-based assessment)
  • 6.7 days earlier discharge; 63% reduction in pharmacotherapy
  • Rooming-in and breastfeeding are therapeutic—mother IS the treatment

💡 Speaker Tip

Ask: "Has anyone seen ESC implemented?" Share success stories if available.

Slide 9: Care Models Comparison 4 min

📢 Key Talking Points

  • No single model is sufficient—layered approach is evidence-based
  • Integrated OB-SUD clinic as medical home (69% retention)
  • Residential for those needing housing/safety
  • Postpartum transition bridges the highest-risk period
Slide 10: Interactive Case (Jane) 8 min

📢 Facilitation Guide

  • Present case; allow 2-3 minutes for small group discussion
  • Ask: "What would you say first to Jane?"
  • Desired response: Acknowledge fear, demonstrate transparency about consent
  • Click "Reveal Teaching Point" after discussion

🎯 Common Discussion Points

  • Some may suggest reassuring Jane she won't lose custody—acknowledge uncertainty but emphasize documentation of strengths
  • Connect to peer recovery specialist as trust-builder
Slide 11: Ethics 4 min

📢 Key Talking Points

  • Person-first language: "person with OUD" not "addict"
  • Consent for testing—verbal screening preferred, biological testing requires explicit consent
  • Balancing mandatory reporting with therapeutic alliance
Slide 12: AIM 5 R's Framework 3 min

📢 Key Talking Points

  • Readiness: Train staff, stock naloxone, develop protocols
  • Recognition: Universal SBIRT
  • Response: Warm handoffs within 72 hours
  • Reporting: Quality metrics dashboard
  • Respectful Care: Patient advisory boards, person-first language
Slide 13: Consultation Algorithm 3 min

📢 Key Talking Points

  • Every transition requires warm handoff: direct communication, appointment scheduled, medication secured, Plan of Safe Care reviewed
  • Postpartum: weekly to monthly touchpoints, MOUD continuation ≥12 months
Slide 14: Knowledge Check 5 min

📢 Facilitation Guide

  • Read question; take votes (raise hands for A, B, C, D)
  • Click selected option to reveal correct/incorrect
  • Emphasize ESC evidence: 6.7 days earlier discharge, 63% reduction in pharmacotherapy
Slides 15-18: Summary & Conclusion 9 min

📢 Key Talking Points

  • Review 10 key teaching points
  • Emphasize equity considerations
  • Provide resource list for follow-up
  • Leave 3-5 minutes for questions

Anticipated Q&A

Q: How do I convince my OB colleagues to prescribe buprenorphine?

Frame it as pregnancy being the highest-motivation window. The X-waiver was eliminated in 2023—any DEA-licensed prescriber can now prescribe buprenorphine. Offer to co-manage, provide a consult line, and share the evidence on retention and birth outcomes.

Q: What if CPS is already involved when the patient presents?

Engage CPS as part of the team when possible. Emphasize that treatment engagement is protective. Document all care participation meticulously—this becomes evidence in custody proceedings.

Q: What about polysubstance use (stimulants, benzodiazepines)?

Polysubstance use is the rule, not the exception. Address each substance: continue MOUD for OUD; counsel on stimulant risks; avoid/taper benzodiazepines due to overdose risk. Harm reduction is still the framework—don't withhold MOUD if other substances are present.

Q: How do we handle pain management in labor for patients on high-dose MOUD?

Continue baseline MOUD—does NOT provide analgesia. Use regional anesthesia first-line. Avoid partial agonist-antagonists. May need 30-50% higher doses of short-acting opioids. Anesthesia consult in 3rd trimester is recommended.

Q: Is breastfeeding safe on methadone or buprenorphine?

Yes—breastfeeding is encouraged if mother is stable on MOUD, HIV-negative, and not using other substances. Transfer to breastmilk is minimal, and breastfeeding may reduce NAS severity and supports attachment.

Key Messages to Reinforce

  1. The dyad is the unit of care. Treating mother and infant separately misses the attachment and co-regulation benefits.
  2. Integration saves lives. Co-located OB-SUD care reduces preterm birth by 55% and improves MOUD retention.
  3. The fourth trimester is the highest-risk period. 75% of maternal drug-related deaths occur postpartum.
  4. Harm reduction over punishment. No discharge for relapse; maintain engagement through recurrence.
  5. Equity requires intention. Standardized protocols reduce racial disparities in screening and treatment.

Required Materials