Slide 01

Title Slide

2 min

Speaker Notes

  • Welcome the audience with warmth; this is a heavy but vital topic
  • Establish credibility — cite your experience with perinatal populations
  • Preview the disclosure: off-label medications, evidence-based vs. institutional protocols
  • Set expectation: interactive cases ahead; participation encouraged
💡 Tip: Make eye contact with the back row during welcome. Say: "The statistics I'm about to share are devastating — but we can change them."
→ Transition: "Today we'll cover the highest-risk period that most clinicians miss..."

Anticipated Questions

Q1: Is this presentation accredited for CME?

A: This session is approved for 1.0 CME credit. Instructions for claiming credit were emailed with your registration.

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Q2: Will slides be available after?

A: Yes — PDF will be emailed within 24 hours. The interactive HTML version is available in the shared resource folder.

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Slide 02

Learning Objectives

3 min

Speaker Notes

  • Read each objective clearly; emphasize "systems-based practice" as often overlooked
  • Point out that this bridges psychiatry, OB, and pediatrics
  • Mention that many attendees may be seeing only part of this patient journey
💡 Tip: Ask for a show of hands: "How many of you see pregnant/postpartum patients in your practice?" — creates engagement.
→ Transition: "Let's start with why this period matters so much..."

Anticipated Questions

Q1: Will we cover medication-assisted treatment dosing?

A: Yes — dosing and management for both buprenorphine and methadone are covered in Slides 6-7.

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Slide 03

Why This Matters — Epidemiological Context

4 min

Speaker Notes

  • Pause on "7-12 months" — let this statistic land
  • Explain the "fragmentation" concept: prenatal programs discharge, insurance changes, OB handoff
  • Mention sleep deprivation as overlooked relapse trigger
  • Emphasize: the patient stable in your prenatal clinic is at GREATEST risk months later
⚠️ Watch for: Audience assuming risk peaks during pregnancy. Correct gently: "Actually, pregnancy is often a protective period."
🎯 Key Point: Continuity of care is not optional — it's lifesaving.
→ Transition: "So what principles should guide our care?"

Anticipated Questions

Q1: What about the immediate postpartum period — first month?

A: Risk is present but not peak. The 7-12 month window combines loss of medical contact, return of fertility, relationship stress, and accumulated sleep debt.

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Q2: Is this data specific to OUD or all substances?

A: The 7-12 month risk window is most pronounced for opioids due to physiological changes and tolerance loss, but elevated risk exists across substances.

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Slide 04

Five Core Principles

5 min

Speaker Notes

  • Read each principle deliberately
  • On Principle #2: emphasize "both" — many think only buprenorphine is safe for breastfeeding
  • On Principle #4: "NAS is NOT a reason to withhold MOUD" — this is a BOARD TRAP
  • Principle #5 sets up the CPS discussion later
🎯 Key Point: If they remember only ONE thing: Don't stop MOUD postpartum.
→ Transition: "Let's apply these principles to a real case..."

Anticipated Questions

Q1: Should patients be on MOUD indefinitely?

A: For most, yes. MOUD is evidence-based treatment, not a bridge to abstinence. Tapering should only occur with patient-driven, informed consent and robust support.

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Q2: What about patients who want to "get off everything"?

A: Explore motivation. If truly informed and refusing, document extensively. But 59-90% relapse rate means this is rarely truly informed consent. Consider ethics consult.

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Slide 05

Case 1 — Maria

5 min

Speaker Notes

  • Read case details slowly; let audience formulate their response
  • Pause after "Should I stop my medication..." — this is the trap
  • Take 2-3 audience responses before revealing
  • Click reveal button AFTER discussion
⚠️ Watch for: Trainees suggesting supervised withdrawal or taper. Correct immediately.
🎯 Key Point: NAS is evidence of treatment, not failure. Frame as positive.
💡 Tip: Say: "Maria thinks she's causing harm by staying in treatment. Our job is to reframe that narrative."
→ Transition: "Let's look at the evidence for our MOUD choices..."

Anticipated Questions

Q1: What if the infant has severe NAS requiring prolonged treatment?

A: Still not a reason to stop maternal MOUD. Coordinate with NICU, maintain mom on medication, prioritize breastfeeding, document NAS as expected. Severe NAS is rare and manageable.

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Q2: How do you counsel a patient who feels guilty about NAS?

A: "Your baby is showing signs because you were in treatment — that's what kept both of you alive. Without your medication, we might not be having this conversation."

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Slide 06

MOUD Comparison Table

4 min

Speaker Notes

  • Walk through each row deliberately
  • Emphasize "NAS severity NOT dose-dependent" — board test item
  • Note that combination product CAN resume postpartum (often not known)
  • Mention MOTHER trial as landmark reference
🎯 Key Point: Both medications work. Choice is shared decision-making, not one-size-fits-all.
→ Transition: "What about breastfeeding specifically?"

Anticipated Questions

Q1: Is buprenorphine safer than methadone in pregnancy?

A: MOTHER study showed shorter NOWS with buprenorphine, but both are safe. Choice is shared decision-making. Cite: Jones et al., NEJM 2010.

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Q2: What dose of buprenorphine is considered "high"?

A: Typical maintenance is 8-24mg. There's no absolute "high" threshold — dosing is symptom-driven. NAS severity doesn't correlate with dose anyway.

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Q3: Can you start buprenorphine in the ED?

A: Yes, with appropriate monitoring. X-waiver no longer required as of 2023. See SAMHSA guidance.

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Slide 07

Breastfeeding & Medications

4 min

Speaker Notes

  • Emphasize: active ILLICIT use is the contraindication, not MOUD
  • Point out sertraline as first-line for PPD (sets up next slide)
  • Stimulants = hard no — significant transfer, CV risk
⚠️ Watch for: Audience members who think buprenorphine = "bad for baby." Correct with relative infant dose data.
🎯 Key Point: Benefits of breastfeeding on MOUD outweigh minimal medication risk.
→ Transition: "Speaking of mental health — let's address the depression component..."

Anticipated Questions

Q1: What about naltrexone for breastfeeding mothers?

A: Limited data but likely safe. Discuss risks/benefits with patient. If patient stable on naltrexone pre-pregnancy, risk of switching may exceed breastfeeding concerns.

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Q2: Can patients breastfeed if they have polysubstance use?

A: Individualized assessment. Cannabis alone is not automatic contraindication. Stimulants are. Key is HONEST assessment of ongoing use.

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Slide 08

Postpartum Depression & SUD

4 min

Speaker Notes

  • "Synergistic" — emphasize bidirectional relationship
  • Screening timeline is critical: 2 weeks, 6 weeks, 3 months, 6 months
  • Note GAD-7 — anxiety often drives relapse, not just depression
  • PCL-5 important for trauma-informed care
🎯 Key Point: Untreated PPD is the strongest predictor of postpartum relapse.
→ Transition: "Let's turn to the neonatal outcomes — specifically NAS..."

Anticipated Questions

Q1: Should we screen dads/partners for depression too?

A: Yes — partner mental health affects maternal outcomes. Partner substance use is the strongest environmental relapse trigger. Screen when possible.

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Q2: What about patients who refuse SSRIs?

A: Psychotherapy (IPT/CBT), peer support, recovery housing. Document informed refusal. Revisit medication conversation at follow-up.

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Slide 09

Neonatal Abstinence Syndrome Overview

4 min

Speaker Notes

  • Read "Key Insight" box slowly — let it sink in
  • Emphasize: NAS is expected, treatable, time-limited
  • Point out 20-40% pharmacologic treatment rate — most DON'T need meds
  • Framing: NAS = evidence of treatment engagement
💡 Tip: This slide often generates emotional response. Acknowledge it: "I know this is hard. But the data is clear."
→ Transition: "Here's how we manage it clinically..."

Anticipated Questions

Q1: Do you tell patients prenatally about NAS risk?

A: Yes — prenatal framing is critical. Patients who understand NAS before delivery cope better, experience less guilt, and stay in treatment.

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Q2: What's the longest you've seen NAS last?

A: Typically 5-7 days, occasionally 2-4 weeks for severe cases requiring pharmacotherapy. Buprenorphine-exposed infants have shorter courses than methadone-exposed.

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Slide 10

NAS Management Algorithm

4 min

Speaker Notes

  • Walk through algorithm left to right
  • Emphasize supportive care FIRST — most infants don't need morphine
  • ESC model reduces pharmacologic treatment by ~50%
  • Finnegan scoring: ≥8 ×3 or ≥12 once = threshold
🎯 Key Point: Eat, Sleep, Console (ESC) — non-pharmacologic interventions work.
→ Transition: "Now let's look at a legal/ethical challenge..."

Anticipated Questions

Q1: What if the mother wants to leave AMA when NAS is diagnosed?

A: Engage social work, address fears (often CPS-related), emphasize that leaving won't prevent NAS and may trigger CPS investigation. Document informed consent discussion.

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Q2: Is there a role for phenobarbital in NAS?

A: Second-line if morphine inadequate. Some centers use for polysubstance exposure. Not first-line for isolated opioid exposure.

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Slide 11

Case 2 — Child Protective Services

5 min

Speaker Notes

  • This case generates strong audience reactions — be prepared
  • Emphasize: cannabis + methadone = NOT automatic child abuse
  • Safe harbor provisions exist in many states
  • Your role: document, advocate, frame narrative
⚠️ Watch for: Audience assuming CPS involvement = patient failed. Reframe: CPS involvement is an opportunity for support.
🎯 Key Point: Proactive CPS navigation > reactive damage control.
→ Transition: "Let's look at the legal framework in detail..."

Anticipated Questions

Q1: Do I have to report positive cannabis to CPS?

A: Depends on state law. Many states have safe harbor provisions for patients in treatment. Know YOUR jurisdiction's requirements. Hospital policy ≠ legal requirement.

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Q2: What if CPS asks for information I'm not comfortable sharing?

A: Consult hospital legal/risk management. You can provide factual information about treatment engagement without violating confidentiality. Frame everything around recovery.

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Q3: Can the patient refuse drug testing?

A: Yes, but consequences vary by state. Some states presume parental rights termination for refusal. Others don't. Document informed consent/refusal.

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Slide 12

Navigating Mandatory Reporting

3 min

Speaker Notes

  • Read each pitfall clearly
  • Emphasize: "Punitive policies increase mortality" — this is data, not opinion
  • Protective documentation = your ally
💡 Tip: "The same documentation that protects your patient protects you."
→ Transition: "Let's return to the highest-risk window..."

Anticipated Questions

Q1: What if my state's laws ARE punitive?

A: Advocate for policy change through professional organizations. In the meantime: perfect documentation, frame narrative around recovery, connect patients with legal advocates.

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Slide 13

The 7-12 Month Window

3 min

Speaker Notes

  • Visual timeline — point to each phase
  • Red highlight on 7-12 months = CRITICAL
  • List risk factors: loss of OB follow-up, treatment gaps, fertility return, relationship stress, sleep deprivation, partner use
🎯 Key Point: The patient you discharge from prenatal care needs a warm handoff. The gap kills.
→ Transition: "So how do we maintain continuity?"

Anticipated Questions

Q1: What if the patient doesn't show for postpartum appointments?

A: Reach out proactively. Phone calls, home visits if available, coordination with OB. Flag as high-risk for outreach. Don't wait for them to come to you.

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Slide 14

Practical Pearls

3 min

Speaker Notes

  • Telehealth fills the gap when patients can't travel with newborns
  • Recovery housing accepting infants dramatically improves outcomes
  • Partner substance use = strongest environmental trigger — screen for it
  • Sleep deprivation is real and dangerous — help build realistic care plans
🎯 Key Point: Partner use screening is as important as patient screening.
→ Transition: "Let's look at the full handoff protocol..."

Anticipated Questions

Q1: What if the partner refuses to get treatment?

A: Harm reduction. Discuss overdose prevention, naloxone, safe sleep arrangements. Consider whether couple can safely cohabitate. Recovery housing may be safer option.

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Slide 15

Warm Handoff Protocol

3 min

Speaker Notes

  • Walk through each phase of the handoff
  • Emphasize documentation that travels with patient
  • Monthly psychiatry in 2-12 months = critical
⚠️ The Gap: Patients lost in transition are the ones who die. Identify them. Call them. Keep them.
→ Transition: "Let's test our understanding..."

Anticipated Questions

Q1: Who owns the warm handoff — OB or psychiatry?

A: Shared ownership. OB should notify psychiatry of delivery; psychiatry should reach out within 1-2 weeks. System-level: care coordinators can bridge.

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Slide 16

Knowledge Check

3 min

Speaker Notes

  • Give audience 30 seconds to consider before revealing
  • Take votes by show of hands if room permits
  • Emphasize WHY B is correct — NAS not dose-dependent
🎯 Key Point: This is a common board trap. Maternal stabilization always comes first.
→ Transition: "Let's summarize our key takeaways..."

Anticipated Questions

Q1: What if the grandmother is demanding the patient taper?

A: Include in family meeting if patient consents. Educate family on NAS pathophysiology. Emphasize that tapering increases risk to mother AND doesn't prevent NAS.

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Slide 17

Bottom Line Summary

3 min

Speaker Notes

  • Read each summary point with emphasis
  • This is the "if they remember nothing else" slide
  • Slow down — let each principle land
💡 Tip: "Write this down. Tattoo it on your brain. This saves lives."
→ Transition: "For further reading and resources..."

Anticipated Questions

Q1: How do I approach a patient who had a bad experience with CPS before?

A: Acknowledge trauma. Don't minimize. Frame current CPS involvement as opportunity for support with documentation. Offer to coordinate directly. Patient may have advocate present.

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Slide 18

References & Resources

2 min

Speaker Notes

  • Mention MOTHER trial as must-read landmark
  • SAMHSA guidance is free and comprehensive
  • MotherToBaby for patient resources
  • Thank audience; open for final questions
→ Transition: "Thank you. Questions?"

Anticipated Questions

Q1: Where can I find state-specific mandatory reporting laws?

A: Guttmacher Institute maintains current database. Hospital legal/risk management should also have summary. Keep updated — laws change.

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Session Timing

0:00–0:05 Introduction & Objectives
0:05–0:13 Epidemiology & Core Principles
0:13–0:27 MOUD, Breastfeeding & NAS
0:27–0:36 Cases & Legal Framework
0:36–0:42 Risk Window & Handoff Protocol
0:42–0:45 Knowledge Check & Summary