Interventions to Support Engagement in Addiction Care Postpartum: Principles and Pitfalls

Figures & data

Table 1 Collaborative Care Interventions to Support Engagement in Addiction Care Postpartum

Authors	Model	Conclusions
Hensel et al (2022)^Citation46	Clinic for Acceptance Recovery and Empowerment (CARE)	40 of 42 CARE patients (95%) were exclusively breastfeeding at discharge and were significantly more likely to be breastfeeding at discharge compared to control patients (adjusted relative risk (aRR): 1.28, 95% confidence interval [CI]: 1.05–1.55).
Hodgins et al (2019)^Citation47	Collaborative Outreach and Adaptable Care at Hallmark Health (COACHH)	Qualitative interviews demonstrated that the 20 patients served over 18 months felt an increase in trust with their provider
Mittal and Suzuki (2017)^Citation48	Reproductive Psychiatry Consultation Service (RPCS)	14 (87.5%) post-partum people continued or resumed treatment with buprenorphine at discharge, and 13 (81.3%) were referred to a community prescriber.

Table 2 Barriers and Strategies of Evidence-Based Harm Reduction Strategies to Support Engagement in Addiction Care Postpartum

Evidence-Based Harm Reduction Strategy^Citation54,Citation60	Potential Barriers to Access (SU or Postpartum Related)	Strategies to Reach People During Postpartum
Naloxone	People caring for an infant may experience stigma seeking naloxone at a pharmacy or syringe service program Family medicine and obstetricians under-prescribe naloxone Home visiting programs are not often equipped with access to naloxone or the ability to provide it to their clients Education on the higher potential for overdose in the event of return to use is not routinely provided^Citation61,Citation62	Prescribe and provide naloxone at the time of delivery and at postpartum care visits to anyone who has used drugs associated with overdose in the past year (eg, fentanyl, heroin, methamphetamine) Provide naloxone training to home visitors and prepare them to provide training to people who live with someone at risk for overdose Improve access to peer doulas who have awareness of specialized considerations at the intersection of postpartum and substance use disorder
Safer use supplies (eg, injection, smoking, booty bumping)/ Non-injecting routes of administration	Women often rely on partners for access to supplies and injection^Citation63,Citation64	Provide protected space to access supplies and safer use practices education specific to women and other previously pregnant people
Safe use sites	The safe use sites that do exist do not offer support navigating childcare considerations^Citation65,Citation66 Safe use sites may need to be aware of postpartum health risks to alert emergency services if needed	Improve access to safe, affordable, and low barrier, childcare for people who use drugs to reduce the likelihood of unsafe use and promote child wellbeing and safety Provide training around postpartum-specific overdose risks and overdose intervention to safe injection site workers
Sexually transmitted infections screening and treatment	Insurance coverage barriers during postpartum^Citation67,Citation68 Admitting substance use or multiple partners with a child in or not in care may jeopardize custody Screening is not part of routine postpartum appointments and postpartum appointments are not well attended by people who use drugs	Make postpartum care more accessible and more frequent that the ACOG recommended two visits through mobile outreach to people who use drugs and include regular low barrier STI testing^Citation69
Access to pre-exposure prophylaxis (PrEP)	Uptake of PrEP is generally low in cis-gender women who inject drugs	Provide PrEP education and access at prenatal and postpartum visits to women who use drugs and are at high risk of HIV infection
Outreach (certified peer and network based)	Peers often lack specialized training in postpartum care needs Network-based strategies may be prone to in-group stigma against people who have been recently pregnant and are using drugs^Citation70	Provide harm-reduction training and education specific to postpartum for certified and network-based peers through community capacity building
Decriminalization and legalization	Despite decriminalization, “unfit mother” narratives continue into postpartum and may result in punitive consequences within the child welfare system	Institute specific systems of support and protection (eg, specifying the actual evidence-based potential harms of certain substances rather than allowing arbitrary decision-making, putting access to support before child removal)

Table 3 Harm Reduction Principles and Postpartum Applications

Harm Reduction Principles	Postpartum Applications
Humanism Respect each person, seeking understanding for why a person makes the choices they do, rather than making moral judgements, holding a grudge, or non-acceptance of patient choices	Ask the individual to describe their own health goals, providing a menu of options related to postpartum health Identify individual drivers of substance use and help support the person in addressing those challenges, without communicating a need to stop using substances or using fear-based language around child removal and child safety
Pragmatism There is no such thing as “perfect” health behaviors, behavior happens in social and cultural context, choosing behaviors that might seem “unhealthy” may have other health benefits not realized the current systems of care	Emphasize individual strengths and co-identify reasons for engaging in “unhealthy” behaviors that are conferring benefit for the individual (eg, continuing to spend time with a partner who the court has ordered them to avoid) Identify potential risks associated with use and provide support to reduce negative health outcomes associated with risk; this may include coming up with safer use plans together with the individual Provide reproductive health counseling in line with a person’s own goals related to contraception Help facilitate access to regular STI and pregnancy screening if a person is unable or uninterested in using barrier methods, is engaging in sex work, or otherwise has multiple partners
Individualism Each person has unique strengths and challenges which requires tailored intervention options	Provide health systems navigation support through peer doula support or another paraprofessional with knowledge of both addiction and postpartum^Citation83–86 Identify opportunities that build on individual strengths and create opportunity for good failure through supportive systems (eg, identifying a safe person to provide childcare that a person can call if they plan to use)^Citation87 Provide actual support around infant sleep, rather than brief education, such as volunteers or community health workers to provide overnight support who are knowledgeable about safe sleep implementation^Citation88
Autonomy Providers offer education and patients make decisions; providers may offer their opinion after asking for permission to offer advice	Ask for permission before offering information about substance use treatment, contraception, and other resources Provide information that is patient centered (eg, an easy-to-read handout on local harm reduction services with visuals to improve understanding)^Citation89
Incrementalism Changes take time, even years, and steps away from a person’s goal may also happen, it’s important to celebrate the small changes	Center the provider’s goal on having and maintaining a relationship, rather than on a specific agenda^Citation90 Check-in frequently and provide support to help people even with small tasks like completing necessary forms to access social benefits and provide praise when those things are accomplished
Accountability without termination No one is ever “fired” for not meeting their own goals, people have the right to make their own choices, even if those choices might cause them harm. A provider’s role is to help them identify their goals and make sense of the consequences that naturally follow.	Never “fire” or stop working with someone who is not making the “right” progress related to their use, use behaviors, or postpartum health Connect choices with consequences and provide opportunities to try again (eg, if a person decides to leave treatment with their newborn, allow them to come back if they would like or provide them with a safe place to receive support that is better aligned with their goals)

Hensel D, Helou NE, Zhang F, et al. The impact of a multidisciplinary opioid use disorder prenatal clinic on breastfeeding rates and postpartum care. Am J Perinatol. 2022. doi:10.1055/s-0042-1748526

 Web of Science ®Google Scholar

Hodgins FE, Lang JM, Malseptic GG, Melby LH, Connolly KA. Coordinating outpatient care for pregnant and postpartum women with opioid use disorder: implications from the COACHH program. Matern Child Health J. 2019;23(5):585–591. doi:10.1007/s10995-018-2683-y

 PubMed Web of Science ®Google Scholar

Mittal L, Suzuki J. Feasibility of collaborative care treatment of opioid use disorders with buprenorphine during pregnancy. Subst Abuse. 2017;38(3):261–264. doi:10.1080/08897077.2015.1129525

 PubMed Web of Science ®Google Scholar

Hawk KF, Vaca FE, D’Onofrio G. Reducing fatal opioid overdose: prevention, treatment and harm reduction strategies. Yale J Biol Med. 2015;88(3):235–245.

 PubMedGoogle Scholar

Ritter A, Cameron J. A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs. Drug Alcohol Rev. 2006;25(6):611–624. doi:10.1080/09595230600944529

 PubMed Web of Science ®Google Scholar

Brown HL. Opioid management in pregnancy and postpartum. Obstet Gynecol Clin North Am. 2020;47(3):421–427. doi:10.1016/j.ogc.2020.04.005

 PubMed Web of Science ®Google Scholar

Rankin L, Mendoza NS, Grisham L. Unpacking perinatal experiences with opioid use disorder: relapse risk implications. Clin Soc Work J. 2023;51(1):34–45. doi:10.1007/s10615-022-00847-x

 Web of Science ®Google Scholar

El-Bassel N, Shaw SA, Dasgupta A, Strathdee SA. People who inject drugs in intimate relationships: it takes two to combat HIV. Curr HIV/AIDS Rep. 2014;11(1):45–51. doi:10.1007/s11904-013-0192-6

 PubMed Web of Science ®Google Scholar

Morris MD, Andrew E, Tan JY, et al. Injecting-related trust, cooperation, intimacy, and power as key factors influencing risk perception among drug injecting partnerships. PLoS One. 2019;14(5):e0217811. doi:10.1371/journal.pone.0217811

 PubMed Web of Science ®Google Scholar

Kashak D. An overview of issues, impacts and services for women who are using substances and are pregnant or parenting within the City of Thunder Bay. Thunder Bay Thunder Bay Drug Strategy. 2015.

 Google Scholar

Mitra S, Rachlis B, Krysowaty B, et al. Potential use of supervised injection services among people who inject drugs in a remote and mid-size Canadian setting. BMC Public Health. 2019;19(1):284. doi:10.1186/s12889-019-6606-7

 PubMedGoogle Scholar

Daw JR, Winkelman TNA, Dalton VK, Kozhimannil KB, Admon LK. Medicaid expansion improved perinatal insurance continuity for low-income women. Health Aff Proj Hope. 2020;39(9):1531–1539. doi:10.1377/hlthaff.2019.01835

 PubMed Web of Science ®Google Scholar

Daw JR, Kolenic GE, Dalton VK, et al. Racial and ethnic disparities in perinatal insurance coverage. Obstet Gynecol. 2020;135(4):917–924. doi:10.1097/AOG.0000000000003728

 PubMed Web of Science ®Google Scholar

McKinney J, Keyser L, Clinton S, Pagliano C. ACOG Committee Opinion No. 736: optimizing postpartum care. Obstet Gynecol. 2018;132(3):784–785. doi:10.1097/AOG.0000000000002849

 PubMed Web of Science ®Google Scholar

Williams LD, Mackesy-Amiti ME, Latkin C, Boodram B. Drug use-related stigma, safer injection norms, and hepatitis C infection among a network-based sample of young people who inject drugs. Drug Alcohol Depend. 2021;221:108626. doi:10.1016/j.drugalcdep.2021.108626

 PubMed Web of Science ®Google Scholar

Stubbs JL. Harm reduction throughout the opioid crisis: a community responds. Br Columbia Med J. 2019;2019:61.4.

 Google Scholar

Bosk EA, Paris R, Hanson KE, Ruisard D, Suchman NE. Innovations in child welfare interventions for caregivers with substance use disorders and their children. Child Youth Serv Rev. 2019;101:99–112. doi:10.1016/j.childyouth.2019.03.040

 PubMed Web of Science ®Google Scholar

Marchand K, Beaumont S, Westfall J, et al. Conceptualizing patient-centered care for substance use disorder treatment: findings from a systematic scoping review. Subst Abuse Treat Prev Policy. 2019;14(1):37. doi:10.1186/s13011-019-0227-0

 PubMed Web of Science ®Google Scholar

Pantridge CE, Charles VA, DeHart DD, et al. A qualitative study of the role of peer support specialists in substance use disorder treatment: examining the types of support provided. Alcohol Treat Q. 2016;34(3):337–353. doi:10.1080/07347324.2016.1182815

 Web of Science ®Google Scholar