Staff Training

Overview with Pregnancy-specific Considerations

This section provides an overview of things to consider when training jail staff regarding MOUD (also referred to as MAT) for pregnant patients in custody. It outlines the basics of MOUD, the fundamental components of a jail-based MOUD program, and includes items you should incorporate in training like patient counseling and non-judgmental care.

Print
Overview with Pregnancy-specific Considerations

HOW 

  • Assess your staff training needs related to MOUD in custody and MOUD for pregnant individuals in custody. If you are just starting a MOUD program, your staff would benefit from all trainings. If you already have an established MOUD program in your facility, you may want to focus on trainings specific to pregnant individuals including things like counseling and stigma. For assistance, view the checklists in the resources and consider seeking technical assistance (see MOMCARE Technical Assistance).
  • Determine the logistics for training staff including who will be the trainer, who will participate, how it will be delivered (in-person or virtual), the timing of delivery, how often it will be delivered, and how you will assess for knowledge and skill retention.
  • Administrators must develop a plan to provide supervision and support to staff throughout the process. This includes providing a space for open dialogue without fear of consequences to address misconceptions and false beliefs regarding addiction, MOUD in general, and in pregnancy.
  • Regularly monitor your MOUD program processes (e.g. screening, dosing, linkage to care at release) to determine if training refreshers are needed. Soliciting feedback from staff who deliver and patients who receive this care can also inform training.

WHY 

  • MOUD has been the long-established evidence-based treatment for individuals who use opioids, including in pregnancy.
  • A prepared workforce produces standardized care and better outcomes for both the facility and patients.

KEEP IN MIND

  • Some staff may have very limited knowledge of what MOUD is including benefits for people who use opioids. Starting with basic fundamental education on addiction and opioid use is necessary.
  • Jail leadership should provide ongoing staff supervision and support to make sure staff needs and concerns are addressed regarding MOUD implementation. This could take many forms including regular one-on-one or group check-ins, anonymous question/feedback submissions, etc.
  • If you partner with an OTP or outside provider to provide MOUD in custody, they should receive training on custody MOUD protocols and procedures specific to your setting (see training checklist for community organizations)
  • You can reach out to your local health department to find out if they offer in-person training on MOUD and MOUD in pregnancy.
  • Training materials should include facility-specific information that references your protocol for pregnant patients in custody and those with OUD

🤰PREGNANCY-SPECIFIC CONSIDERATIONS

Staff should be trained on care and situations specific to pregnant patients like:

  • Urgent maternal warning signs
  • When to transport a pregnant patient to the hospital for labor/birth or a higher level of care
  • Abortion access
  • Postpartum care
  • Restraint use
  • Stigma and language
  • MOUD counseling

HOW 

Action Items

  1. Assess your staff training needs related to MOUD in custody and MOUD for pregnant individuals in custody. If you are just starting a MOUD program, your staff would benefit from all trainings. If you already have an established MOUD program in your facility, you may want to focus on trainings specific to pregnant individuals including things like counseling and stigma. For assistance, view the checklists in the resources and consider seeking technical assistance (see MOMCARE Technical Assistance).
  2. Determine the logistics for training staff including who will be the trainer, who will participate, how it will be delivered (in-person or virtual), the timing of delivery, how often it will be delivered, and how you will assess for knowledge and skill retention.
  3. Administrators must develop a plan to provide supervision and support to staff throughout the process. This includes providing a space for open dialogue without fear of consequences to address misconceptions and false beliefs regarding addiction, MOUD in general, and in pregnancy.
  4. Regularly monitor your MOUD program processes (e.g. screening, dosing, linkage to care at release) to determine if training refreshers are needed. Soliciting feedback from staff who deliver and patients who receive this care can also inform training.

Training needs will differ by facility but we encourage everyone to complete trainings on the basics of MOUD in pregnancy, MOUD in a carceral setting, and stigma and language (see subsequent sections for details). All staff should be aware of their facility’s MOUD program model, staffing design, and organizational needs. Medical and security staff who are directly involved in the provision of MOUD in their facility should receive additional training.  Although some topics only pertain to medical staff and others to custody officers, both groups must understand each other’s roles and expectations. We highly recommend that these core staff, if not all staff, engage in training related to values, behaviors, trauma-informed care, and stigma.

Jails should consider the following items to determine how they will train staff regarding MOUD for pregnant individuals in custody:

  • The best way to deliver content (e.g. in-person trainings, webinars, case examples/simulation activities, individual vs group training, etc.)
  • How often staff should be retrained/engage in training activities
  • Who should participate in training and who should deliver the training
  • The best way to foster buy-in and increase knowledge regarding MOUD for pregnant patients in jail

We suggest that staff be trained at the inception of their MOUD program or when there are changes to their MOUD program. New staff should be trained during onboarding. Staff directly involved in MOUD provision should receive more in-depth training and regular refreshers to ensure evidence-based care and prevent diversion.

While in-person training is best for engagement and knowledge retention, we know that it is not always feasible. We provide recommended virtual training as well as where you can go to request in-person training.  All recommended trainings are FREE.

 

🤰PREGNANCY-SPECIFIC CONSIDERATIONS

  • We recommend using this CDC and ACOG resource to train your staff on urgent maternal warning signs, including labor—it can be a brief 20-minute in-service so they know what things to take seriously.
    • The website has some details about why various symptoms are concerning, and this is helpful for training.
    • Print out the flyers—the website has them in English and many other languages—and post them in clinic and housing units where there are pregnant females. This helps the pregnant patients and staff remember what the urgent maternal warning signs are.
  • Use these short training videos to educate your staff on:
  • Train staff on when to transport a patient who might be in labor. Key training points:You cannot diagnose labor just by looking at someone. They need an exam of their cervix by a qualified perinatal clinician.
    • Have a low threshold to transport pregnant patients who might be in labor. Transports to the hospital are a hassle, but they are less of a hassle than a baby being born in jail and the lawsuit that is likely to follow.
    • The signs of preterm labor (< 37 weeks) are even more subtle than labor at term. Have a low threshold to transport a preterm patient who has any vaginal bleeding, leaking fluid, or recurrent cramps/contractions of more than 5 in one hour.
    • Purchase an emergency delivery kit to have at your jail, just in case someone gives birth in jail. They are not very expensive!
      • Have an in-service every year on what’s in the kit and how to use it. You are not training your staff to be midwives or obstetricians, just to know the basics until EMS help has arrived!
    • Abortion Access
      • Train medical staff to know what’s allowed in your state.
      • Train medical staff to ask pregnant patients who are early in their pregnancies (eligible in your state for an abortion) if they want to continue the pregnancy or seek abortion.
      • Use this MOMCARE 1-pager, Abortion in Custody: FAQs for Correctional Staff, to educate correctional staff on why someone might seek an abortion and what jail staff need to know if someone requests and obtains an abortion in custody. 
    • Postpartum Care
      • Identify a lactation consultant at the birthing hospital who can do telehealth visits if women are having problems. Have that person train a champion at your jail to be an onsite resource.
    • Restraint use
      • Train all staff (medical and custody) on the non-use of restraints in pregnancy and postpartum periods. Make sure you comply with your state’s law.
    • Train staff to address stigma and language around drug use and treatment in pregnancy
    • Train staff on topics and techniques for counseling pregnant and postpartum patients about MOUD

WHY

Medications for opioid use disorder (MOUD) have been the long-established evidence-based treatment for individuals who use opioids. This includes methadone and buprenorphine for pregnant patients. However, some jails are now just beginning to offer MOUD to pregnant individuals and others in custody. To optimize treatment retention and results, jails must build MOUD programs that are informed by data while adapting to the correctional environment.

Our goal is to guide jail staff in gaining the knowledge and tools to care for pregnant patients with OUD and execute MOUD in custody. A prepared workforce produces better outcomes for both the facility and patients. There are a lot of misconceptions and stigma around opioid use in general, but especially regarding pregnant individuals. We advise ALL staff (administrators, medical, and line staff) to engage in the training and education materials to increase their knowledge and know-how, as well as to create a jail environment of shared values and openness. Upon training completion, staff should understand how MOUD is compatible with the goals of their facility and understand what role they play.

🤰 Stigma and Judgment

🤰 Stigma and Judgment

This section focuses on staff training related to stigma, trauma-informed language, and biases towards pregnant individuals in jail who use opioids and who may be on MOUD (also referred to as MAT).

Print

HOW 

  • Assess stigma, judgment, and the language used by staff regarding pregnant patients with OUD. Use the MOMCARE Workshop Discussion Guide: Overcoming Stigma & Objections related to Substance Use in Pregnancy to facilitate a group discussion about stigma.
    • There are additional self and group assessments (see Resources tab) to help you better understand stigma within your facility.
  • Educate staff on the evidence-based treatment of MOUD to treat opioid use and address misconceptions like it is substituting one drug for another. Using a licensed medical professional or expert to deliver this information may be most effective.
  • Engage all staff in open dialogue about their thoughts and feelings regarding using MOUD to treat OUD and about pregnant individuals who use substances.
  • Utilize and practice non-judgmental language for patient interactions. Post corrective language reminders in places where jail staff will see them as a daily refresher.
  • Call out and correct staff who use stigmatizing and judgmental language. Use it as a learning opportunity to educate them and practice patient-centered interactions.
  • Allow staff members to voice their thoughts, feelings, and concerns with other staff about substance use and pregnancy. Having an open-door policy promotes learning, growth, and trust among staff.

WHY 

  • Treatment like MOUD can help people who suffer from opioid addiction live healthy and meaningful lives. However, stigma and misconceptions about MOUD, especially in pregnancy, lead to underutilization.
  • Negative treatment experiences deter pregnant individuals with OUD from asking for and getting help in the future.
  • Addiction stigma leads to ostracizing those who use drugs, which further disconnects them from the support and resources needed for recovery.
  • How you speak to, look at, and talk about pregnant patients with OUD matters.

KEEP IN MIND 

  • Addiction is a disease and should be viewed and treated as such, even in pregnancy. Under no circumstances should a pregnant person’s drug use be construed as disregard or lack of care for herself or her baby.
  • Language matters and can greatly impact how patients view themselves and their worthiness of care.
  • MOUD with methadone and buprenorphine is recommended in pregnancy and has both maternal and fetal health benefits.
  • Consider which custody staff within your facility look after pregnant individuals and those with OUD. They should have an attitude that is conducive to positive interactions and building rapport with this unique population.
  • Staff who exhibit a stigmatizing and judgmental manner should be corrected and educated. If they continue to use non-trauma-informed and patient-centered language, they should be reprimanded and should not have any contact with pregnant individuals who use substances.

HOW

Action Items

  1. Assess stigma, judgment, and the language used by staff regarding pregnant patients with OUD. Use the MOMCARE Workshop Discussion Guide: Overcoming Stigma & Objections related to Substance Use in Pregnancy to facilitate a group discussion about stigma. There are additional self and group assessments (see Resources tab) to help you better understand stigma within your facility.
  2. Educate staff on the evidence-based treatment of MOUD to treat opioid use and address misconceptions like it is substituting one drug for another. Using a licensed medical professional or expert to deliver this information may be most effective.
  3. Engage all staff in open dialogue about their thoughts and feelings regarding using MOUD to treat OUD and about pregnant individuals who use substances.
  4. Utilize and practice non-judgmental language for patient interactions. Post corrective language reminders in places where jail staff will see them as a daily refresher.
  5. Call out and correct staff who use stigmatizing and judgmental language. Use it as a learning opportunity to educate them and practice patient-centered interactions.
  6. Allow staff members to voice their thoughts, feelings, and concerns with other staff about substance use and pregnancy. Having an open-door policy promotes learning, growth, and trust among staff.

We recommend that ALL jail staff participate in training related to stigma and judgment regarding addiction and pregnant individuals who use drugs. Ensuring that all staff receive training will help create a jail culture that is compassionate towards this population. Doing so will also foster open dialogues among staff to help each other address stigma through teaching rather than a disciplinary approach if it does occur.

Stigma can be reduced by using person-centered language and recognizing that treatment works. Using words that can reduce stigma like person-first language helps focus on the human being and not his or her condition. Here are some examples of alternative words to use and why to reduce stigma.

Treatment like MOUD can help people who suffer from opioid addiction live healthy and meaningful lives. However, stigma and misconceptions about MOUD, especially in pregnancy, lead to underutilization.

Identifying one’s stigma is vital to actively and intentionally dismantling those beliefs. We suggest that staff complete the short self-assessments on stigma related to pregnant individuals who use drugs to get an understanding of their beliefs. We then encourage staff (administrative, medical, and custody) to facilitate open group discussions about their beliefs while including factual medical and public health information to increase knowledge and shift attitudes.

Stigma will not disappear overnight but it is important to frequently and openly discuss these topics as they arise and hold each other accountable. Regardless of how you may feel, pregnant individuals with OUD deserve evidence-based, respectful care.

WHY 

Stigma related to substance use is discrimination against people who use drugs. It involves the inaccurate labeling of people who use drugs as dangerous and incapable of adhering to treatment. Stigma related to addiction may stem from the belief that drug use is a personal choice. Addiction stigma leads to ostracizing those who use drugs which further disconnects them from the support and resources needed for recovery. Pregnant individuals who use drugs face stigma and judgment and may be labeled as a bad parent or someone who does not care about their baby.

Stigma from jail staff towards pregnant patients who use opioids can have a significant impact on their care experiences as well as their self-esteem and self-worth. Interactions that are not trauma-informed or patient-centered can have lasting effects on pregnant individuals with OUD and be detrimental to their treatment trajectory. Many pregnant individuals who use drugs do not get adequate prenatal care due to fear of judgment from health providers. How you speak to, look at, and talk about pregnant patients with OUD matters. Promoting a non-judgmental care environment for pregnant patients with OUD can help build rapport between the patient and provider and enhance the patient’s treatment experience.

It’s important to remember that negative treatment experiences deter pregnant individuals with OUD from asking for and getting help in the future. It can also lead to self-medicating which exposes the fetus to unsafe fluctuating opioid levels and dramatically increases the risk of overdose death.

“It’s a lot of wasted energy, judging people and labeling them as noncompliant,” he said. “My job isn’t to determine if a patient is deserving of health care. If a patient is sick or has a disease, I have the skills to help, so I’m going to do it.” — Kyle Patton, a family doctor who treats pregnant people who are unhoused and use substances (KFF Health News)

This issue brief addresses common questions and misconceptions about using medications to treat opioid addiction.

This website describes how you can help reduce the stigma around moms and babies. It describes what stigma is, demonstrates narrative examples of stigma, and provides information on how you can be a change-maker.

This toolkit was created by retired Judge Linda Davis when she recognized the stigma, judgment, mistreatment, and lack of services for people with substance use disorders. It describes why words matter and the impact of stigma. 

Resources with individual and group assessments to address stigma:

  • Mothering and Opioids: Addressing Stigma and Acting Collaboratively (Centre of Excellence for Women’s Health, 2019)
    • Practitioner Behaviors and Values (p.11-12)*
    • Examining use of language (p.13)
    • ACTS Scripts to Address Stigmatizing Behaviors by Coworkers (p.14)**
    • 10 Things Pregnant and Parenting Women who use substances would like practitioners to know (p.16)
    • Women who used opioids during pregnancy: Three scenarios for discussion (p.24)**
    • Bringing Evidence-based and Values-based approaches into our work with pregnant and parenting women who use substances (p.26)**
    • Bringing trauma-informed principles into our work with pregnant and parenting women who use substances (p.28)**
  • Improving Linkages to Comprehensive Care for People at Risk of Overdose: A toolkit for Maryland Providers and Community Members (astho & Maryland Department of Health, 2023)
    • 10 things people who use drugs would like practitioners to know (p.13)
    • SAMHSA’s principles for being trauma-informed (p.15)
    • Assessing Trauma-informed care practices (p.17-18)*
    • Discussion questions for understanding and strategies for challenging stigma
      • Leadership questions (p.22)*
      • Individual staff member questions (p.23)*

*Individual staff assessment tools

**Group activities for staff

Screening and Assessment

In this section, you’ll find guidance on the importance of training staff to screen and assess for both pregnancy and opioid use. Identifying pregnant individuals with OUD at intake is essential to getting them into care timely.

Print
Screening and Assessment

HOW 

  • Train all intake staff on procedures for screening for pregnancy and opioid use disorder. See MOMCARE Screening content.
  • Train staff to identify when a pregnant patient is unwell at intake so the patient can be expedited to care or get hospital clearance before admittance to jail.
  • Add pregnancy and OUD screening and assessment procedures to the jail policy including guidelines for retesting if necessary and re-training at a set period.
  • Implement compliance checks to make sure standardized screening and assessment are consistent across shifts and personnel.

WHY

  • To provide MOUD (also referred to as MAT) and supportive services to pregnant patients in custody, jails must first have a systematic way of screening and assessing for pregnancy and opioid use at intake.
  • Ensuring that all staff members are adequately trained in screening and assessment methods will help ensure that pregnancy and opioid use are immediately identified and patients receive the care they need.

KEEP IN MIND 

  • Women may not be aware that they are pregnant. If negative, pregnancy tests should be repeated in 1-2 weeks if the patient believes there is a chance of pregnancy or if there are other clinical indications (i.e. late menstrual cycle) that the patient may be pregnant. See MOMCARE Screening Pregnancy.
  • Some people may be reluctant to share their most recent time of drug use due to fear of legal consequences. Pregnant individuals who use substances may also be hesitant to share that they are using to due fear of involvement with child welfare and stigma and judgment. Jail staff must use their judgment and be as conservative as possible when determining the risk of withdrawal for pregnant individuals. Jail staff should use patient-centered, non-judgmental language and communicate your goal is to get them appropriate treatment. See MOMCARE Screening OUD.
  • Some jail staff may be responsible for screening for pregnancy and OUD but do not have a professional medical background. Staff must be adequately trained so that comprehensive screening is performed consistently.

HOW

Action Items

  1. Train all intake staff on procedures for screening for pregnancy and opioid use disorder. See MOMCARE Screening content.
  2. Train staff to identify when a pregnant patient is unwell at intake so the patient can be expedited to care or get hospital clearance before admittance to jail.
  3. Add pregnancy and OUD screening and assessment procedures to the jail policy including guidelines for retesting if necessary and re-training at a set period.
  4. Implement compliance checks to make sure standardized screening and assessment are consistent across shifts and personnel.

If there is a possibility that a staff member may perform intake processing, even if unlikely, then they should be trained on screening and assessment measures for pregnancy and opioid use.

We do NOT recommend urine drug tests to screen for drug use in pregnancy; national guidelines also support screening with questions, not urine. Urine tests are not always accurate, and in some settings can take a while for results to return.

We provide further guidance on using validated screening tools and other methods to screen for both pregnancy and OUD, see MOMCARE Screening OUD and Screening Pregnancy. We also provide suggested language staff can use for patient interactions.

We suggest using the BJA Management Withdrawal Guidelines to determine if someone is showing signs of being “unwell.”

“Unwell” means that someone has observed signs and symptoms that are obvious to a layperson that they are physically or psychologically sick, including signs of self-reported intoxication or substance withdrawal (see BJA Withdrawal Management Guidelines, p. 5, for more about “unwell”). For a pregnant person, this also includes signs or symptoms of urgent maternal warning signs, like bleeding, pelvic pain, severe headache, contractions, and other symptoms.

WHY

To provide MOUD and supportive services to pregnant patients in custody, jails must first have a systematic way of screening and assessing for pregnancy and opioid use at intake. This involves using evidence-based screening measures and questions to identify folks who use opioids. Training for screening and assessment is important because different staff with varying backgrounds may perform this task. Sometimes it may be someone from the medical team, other times it can be an intake coordinator or custody officer. Ensuring that all staff members are adequately trained in screening and assessment methods will help ensure that pregnancy and opioid use are immediately identified and patients receive the care they need.