Postpartum Overdose Prevention Bundle
Deep Dive Materials

About This Document: Extended materials on the AIM 5-domain overdose prevention bundle: detailed case studies, implementation science frameworks, equity considerations, and policy advocacy strategies.

Extended References & Evidence Base

1. Maine Perinatal Quality Collaborative: Universal Postpartum Naloxone (2022-2024)
Pilot program at rural hospital. 89% acceptance of take-home first aid kits; 73% accepted naloxone. Combined implicit bias training with harm reduction education. Reduced staff stigma scores by 34% and increased patient trust ratings.

2. Massachusetts Population Study: Postpartum MOUD Retention (2021)
n=2,314. 64.1% continued MOUD for 12 months. Risk factors for discontinuation: incarceration (aOR 2.48), ≥3 ED visits (aOR 2.28), anxiety diagnosis (aOR 1.92), infant NAS diagnosis (aOR 2.03).

3. Tele-MOUD Retention Meta-Analysis (2024)
Pooled analysis of 12 studies. Tele-MOUD showed equivalent or superior retention vs in-person for perinatal patients. Key moderators: technology access, digital literacy, hybrid models (telehealth + periodic in-person).

OSCE Cases: Expanded Scenarios

OSCE Case 1: "Missed MOUD Initiation on L&D" — Expanded

Full Scenario: Tamara, 26-year-old G2P1 at 38 weeks, presents to L&D in active labor. Diaphoretic, tachycardic, restless. Discloses daily fentanyl use × 2 years, last use 6 hours ago. No prenatal care. Anxious, asking repeatedly "Am I going to get in trouble? Will they take my baby?"

Learning Objectives & Assessment Criteria

DomainPerformance CriteriaCommon Errors
Communication Uses person-first language; validates fear; demonstrates empathy Judgmental language; dismissive of concerns; focuses on "rules"
Clinical Knowledge Recognizes acute withdrawal; offers MOUD initiation Attempts to "manage" withdrawal without MOUD; delays treatment
Ethics Addresses CPS concerns transparently; emphasizes supportive approach Avoids CPS topic; makes unrealistic promises; creates fear
Systems Activates multidisciplinary team; initiates Plan of Safe Care Works in isolation; delays social work involvement

Faculty Notes

Watch for learners who avoid the CPS conversation entirely—this reflects real-world discomfort but fails to build trust. The "correct" approach includes:

  1. Acknowledging the fear explicitly ("It sounds like you've had experiences that make you worry about CPS")
  2. Explaining the process transparently ("We are required to notify CPS about substance exposure, but this is about getting you services, not punishment")
  3. Emphasizing protective factors ("Getting you on MOUD today is actually protective—CPS wants to see treatment engagement")
  4. Offering Plan of Safe Care as collaborative document

OSCE Case 2: "Postpartum MOUD Discontinuation" — Expanded

Full Scenario: Keisha, 31-year-old, 10 days postpartum after C-section. Was stable on buprenorphine 16 mg throughout pregnancy. Medicaid coverage scheduled to expire at 60 days (state has not yet adopted extension). PHQ-9 score 14 (moderate depression). During postpartum check, mentions she's been "thinking about stopping the buprenorphine since the baby is here." States her partner has been "getting more aggressive lately" and she's worried about having "drugs in the house." Family member told her she "shouldn't need it anymore."

Key Teaching Points

  • Dual risk factors: Depression (PHQ-9 14) and IPV are both independently associated with postpartum overdose
  • Tolerance loss: If she discontinues buprenorphine and later relapses, her tolerance will be reduced—increased overdose risk
  • Social determinants: Insurance discontinuation is a structural barrier, not patient "non-compliance"
  • Motivational interviewing: Explore ambivalence without being prescriptive; use open-ended questions

Suggested Learner Response

"I hear that you're getting different messages about the buprenorphine. Can you tell me more about your concerns about having it in the house? [LISTEN] It sounds like there are some stressors at home. The postpartum period is actually a very high-risk time for overdose, and stopping the medication could increase that risk. Many people stay on buprenorphine for a year or more postpartum. Let's talk about options."

OSCE Case 3: "Universal Naloxone Conversation" — Expanded

Full Scenario: Maria, 22-year-old G1P1, being discharged after uncomplicated vaginal delivery. No documented substance use history. Hospital has adopted universal postpartum naloxone distribution. Nursing staff offers a first aid kit containing naloxone. Maria becomes visibly upset and asks "Why are you giving me this? Do you think I use drugs? Is my baby okay?"

Facilitation Guide

This case tests the learner's ability to normalize harm reduction without creating stigma. Watch for:

  • Defensive responses ("It's just hospital policy")
  • Withdrawal of offer ("You don't have to take it if you don't want it")
  • Failure to address underlying concern ("Your baby is fine, here sign this")

Optimal response: "I can see why this might be confusing. We're giving these kits to every family as part of our postpartum safety program. Just like we teach CPR, we want everyone to have naloxone in case of an emergency—not because we think anything will happen to you, but because it can save a life if anyone in your community has an overdose. This has nothing to do with your medical history."

Implementation Science Framework

Consolidated Framework for Implementation Research (CFIR)

CFIR DomainBarrierStrategy
Intervention Characteristics Naloxone seen as "drug paraphernalia" Reframe as "first aid kit"; emphasize universal benefit
Outer Setting State laws limiting naloxone distribution Standing orders; pharmacist collaborative agreements
Inner Setting Staff discomfort discussing substance use Implicit bias training; practice scenarios
Individuals Provider skepticism about universal approach Share 60-73% statistic; emphasize evidence
Implementation Process Workflow integration challenges EHR order sets; standing orders; automated prompts

Plan-Do-Study-Act (PDSA) Cycles

PDSA Cycle 1: Pilot on One Unit

Health Equity Considerations

Age-Related Disparities

Emerging Finding (2024): Overdose mortality has tripled among pregnant/postpartum women aged 35-44. Likely contributors: higher cumulative exposure, polysubstance use patterns, delayed recognition of risk.

Implications for Bundle:

Racial/Ethnic Disparities

Disproportionate impact on Black, Hispanic, and AI/AN populations requires targeted adaptation:

DisparityAdaptation Strategy
Lower MOUD receipt in Black women (31% vs 57%) Culturally competent peer specialists; community-based outreach
Higher CPS reporting for similar substance use Standardized reporting protocols; implicit bias training
Delayed OUD diagnosis (37 days later) Universal screening; early engagement protocols

Policy Advocacy Strategies

Hospital-Level Policy Changes

  1. Standing Orders: Allow nursing to dispense naloxone without individual prescriptions
  2. EHR Integration: Automated prompts for bundle completion; hard stops for missing elements
  3. Patient Advisory Board: Include women with lived experience in bundle design and refinement
  4. Data Transparency: Publish equity-stratified outcomes; hold leadership accountable

State-Level Advocacy

Priority Policies:
  • 12-month Medicaid postpartum extension (44 states have adopted; advocate in remaining states)
  • Naloxone standing order expansion (all 50 states have some form; strengthen implementation)
  • Fentanyl test strip decriminalization (currently prohibited in 15 states)
  • Good Samaritan law strengthening (protect pregnant callers from prosecution)

Additional Resources