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Perinatal SUD Education Series

Perinatal SUD Care Dyad Package

Five Pillars of Evidence-Based Care

The Minimum Effective Standard for Psychiatry and Obstetrics

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The Problem

Why the Dyad Matters

Traditional siloed care fails: The mother-infant dyad must be conceptualized as a singular biological unit.

Maternal physiology directly impacts fetal neurodevelopment via cortisol and catecholamine surges
Co-regulation capacity is compromised by untreated addiction and trauma
Fragmented care leads to polypharmacy risks, conflicting advice, and the "fourth trimester cliff"

Integration works: OB-Addiction programs cut preterm birth by >50% (11.8% vs 26.6%).

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The Five Pillars

Minimum Effective Dyad-Care Package

I

Universal Screening

Validated tool (4Ps/5Ps) at 1st visit; urine tox only with consent

II

Rapid-Access MOUD

<24-48hr initiation; split dosing in 3rd trimester

III

Psychiatric Comorbidity

Trauma-informed prescribing; avoid benzos; treat PTSD/depression

IV

Plan of Safe Care

Prenatal creation; distinct from CPS report

V

Dyadic Postpartum Transition

Warm handoff; pediatric connection; 12-month MOUD plan; LARC

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Pillar I

Universal Screening

Selective screening based on "suspicion" is scientifically invalid and racially biased.

Tool	Purpose	Key Point
4P's Plus/5P's	Substances + IPV/Depression	Parents, Partners, Past, Present, Pregnancy
NIDA Quick Screen	Substance use severity	First prenatal visit
Urine Toxicology	Diagnostic adjunct ONLY	Requires informed consent—not screening

      Positive screen triggers SBIRT: Immediate, non-judgmental conversation—not punishment.
    

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Pillar II

Rapid-Access MOUD

Withdrawal/detox is NOT recommended in pregnancy. Associated with 59-90% relapse rates.

Initiate buprenorphine or methadone within 24-48 hours of OUD identification
Split dosing (TID/QID) in 3rd trimester—increased CYP3A4 metabolism
Continue baseline MOUD during labor—does NOT provide analgesia
Avoid agonist-antagonists: Nalbuphine, butorphanol precipitate withdrawal

Breastfeeding encouraged if stable on MOUD, HIV-negative, no illicit substance use.

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Pillars III-V

Completing the Package

III. Psychiatric Comorbidity Management

Most women with SUD have PTSD, depression, or bipolar disorder
Avoid benzodiazepines: Exacerbate overdose risk and NAS
Use SSRIs, hydroxyzine, quetiapine for anxiety/insomnia

IV. Plan of Safe Care (POSC)

Federally required under CAPTA/CARA
Created prenatally, distinct from CPS report
Demonstrates stability to prevent unnecessary child removal

V. Dyadic Postpartum Transition

6-12 months = highest overdose risk (75% of deaths postpartum)
Warm handoff; pediatric integration; immediate LARC

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Care Models

Integrated Care Models

Model	Outcomes	Limitation
Integrated OB-SUD Clinic	94% treatment adherence; 87% term deliveries (1st trimester entry)	Most scalable and effective for majority
Residential Program	OR = 0.40 for out-of-home placement; OR = 3.01 for completion	High cost, limited beds
Home-Visiting/Peer	Cultural brokers; critical postpartum safety net	Cannot prescribe MOUD

      "Kitchen Sink" Fallacy: Mandating all services as prerequisites for MOUD access becomes a barrier. Prioritize low-barrier MOUD with voluntary additional services.
    

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Implementation

Psychiatry Curriculum

Module	Competencies
A. Perinatal Pharmacology	CYP3A4 induction, split dosing, lactation, pain management
B. Bioethics	Consent for testing, CAPTA/CARA, bias mitigation, documentation
C. Communication	Warm handoffs, conflict resolution, person-first language
D. Clinical Skills	4P's/5P's, motivational interviewing, pain consults

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Outcomes

Measuring Success

Maternal Outcomes

Treatment retention >70% at 6 months PP
MOUD adherence >90%
Prenatal attendance >8 visits
Overdose events: 0

Infant/Dyadic Outcomes

NAS severity: Decreased pharmacotherapy
Length of stay: <7 days (no meds)
Breastfeeding: Comparable to non-SUD
Discharge: To biological mother

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Conclusion

Key Takeaways

The dyad is the unit of care. Treating mother and infant separately misses attachment benefits.
Five pillars are the minimum effective standard. Universal screening, rapid MOUD, psychiatric integration, POSC, and postpartum transition.
Integration reduces preterm birth by >50%. Co-located OB-SUD clinics are the scalable gold standard.
Avoid the "kitchen sink" approach. Low-barrier MOUD with voluntary services maximizes retention.