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Perinatal SUD Education Series

Postpartum Overdose Prevention Bundle

An Evidence-Based Prevention Protocol

AIM Patient Safety Bundle Adaptation

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The Crisis

The Preventable Epidemic

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Overdose deaths per 100,000 births
(2020) — 81% increase
60-73%
Deaths occur OUTSIDE
healthcare settings
84%
Pregnancy-related deaths
deemed PREVENTABLE
91%
Ohio overdose deaths
deemed preventable
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Evidence

Interventions Across Levels

LevelKey InterventionEvidence
IndividualMOUD retention43.1% vs 28.9% at 6 months
IndividualNaloxone distribution89% acceptance (Maine pilot)
ClinicIntegrated OB-Addiction care69% retention at 6 months
System12-month Medicaid extension+8.55% MOUD months
PolicySupportive vs punitive policies+11% MOUD; -45% overdoses
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Failure Points

Six Points of Preventable Death

Failure PointBundle Response
1. Missed MOUD initiation — No treatment despite OUDUniversal SUD screening + same-day MOUD
2. Early MOUD discontinuation — Insurance loss, stigma12-month Medicaid extension; continuity plan
3. Lack of naloxone — 60-73% deaths outside careUniversal naloxone dispense at discharge
4. Untreated depression/PTSDIntegrated behavioral health; screen at every visit
5. Intimate partner violenceHITS/HARK screening; safety planning
6. Housing instabilitySDOH screening; housing/food/transport connection
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Domain 1

1. READINESS (Every Unit)

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Domain 2

2. RECOGNITION & SCREENING

Tolerance Assessment: Any period of reduced use (incarceration, detox, "quit attempts") markedly increases overdose risk upon return to use.
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Domain 3

3. RESPONSE (Every Event)

A. MOUD Continuity Plan

  • Initiate or continue MOUD; buprenorphine preferred for new starts
  • Do NOT routinely taper postpartum
  • At discharge: next MOUD appointment within 7 days
  • Warm handoff to outpatient MOUD provider

B. Universal Naloxone + Harm Reduction

  • Dispense ≥2-dose nasal naloxone at discharge (standing order)
  • Discuss fentanyl contamination; never-use-alone counseling
  • Review reduced tolerance risk postpartum
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Domain 3 (cont.)

Postpartum Follow-Up Schedule

VisitTimingCore Elements
17–14 days PPMOUD check, mood, feeding, naloxone supply, safety planning
26 weeks PPMOUD, contraception, PHQ-9, Edinburgh, PCL-5
33 months PPMOUD retention, mental health, SDOH update
4+OngoingMonthly touchpoints; coordinate with pediatric visits
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Domains 4-5

4. REPORTING & 5. RESPECTFUL CARE

Reporting & Systems Learning

  • Track bundle compliance
  • Monthly huddles for near-misses
  • Maternal mortality review with SUD lens
  • Disaggregate data by race/ethnicity/payor

Respectful, Equitable Care

  • Person-first, non-stigmatizing language
  • Include patient in all decisions
  • Do NOT condition MOUD on other services
  • Acknowledge structural barriers
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Implementation

Implementation Strategy

PhaseTimelineActivities
1. ReadinessMonths 1-3Gap analysis, identify champions, staff training, EHR order sets
2. PilotMonths 4-9Launch on one L&D unit, weekly huddles, PDSA cycles
3. SpreadMonths 10-18Expand to additional units, quarterly reporting, sustain
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Metrics

QI-Ready Metrics

Process Measures

  • % screened for SUD: ≥95%
  • % naloxone dispensed: ≥90%
  • % follow-up ≤14 days: ≥80%
  • % warm handoff documented: ≥85%

Outcome Measures

  • MOUD continuation 6 weeks: ≥75%
  • MOUD continuation 6 months: ≥65%
  • Overdose events: Trending ↓
  • Patient-reported stigma: Stable/↓
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Conclusion

Summary

  1. 84-91% of pregnancy-associated overdose deaths are preventable.
  2. The 7-12 month postpartum period is the highest-risk window.
  3. The 5-Domain AIM Bundle provides a structured, evidence-based response.
  4. Universal naloxone + MOUD continuity + warm handoffs = prevention.