Overview

Opioid use disorder (OUD) in pregnancy is a major cause of maternal morbidity and mortality. 

• In the last 20 years, opioid use in pregnancy has quadrupled, and opioid-related maternal deaths increased by 81% just from 2017 to 2020! 
• 10% of pregnancy and postpartum deaths are opioid-related.

Many pregnant and postpartum people with OUD may be incarcerated at some point.

• Among the nearly 55,000 admissions of pregnant people to jails each year, at least 14% have OUD.
• Research has shown that incarceration during pregnancy increases the risk of maternal overdose. 

As pregnant and postpartum women cycle in and out of jail, jail is thus an important point along the cascade of care to provide essential, life-saving treatment that can improve outcomes for moms and babies. 

• There may be legal consequences for jails that don’t provide pregnant women with OUD access to standard treatment. 

OUD is a chronic disease of the brain. It involves continued use of opioids, despite harmful consequences to the person’s health and other aspects of their lives. Even though it may seem simple like an individual who is making bad choices, addiction has a biological basis and causes changes in the brain. Just like other chronic diseases such as diabetes or high blood pressure that require ongoing medication treatment, the same is true for OUD.

It may seem confusing to see a pregnant or postpartum woman struggling with OUD—like she doesn’t care about her baby. However, that couldn't be further from the truth. Research has shown that these women care deeply about their baby’s well-being. But their addition is so strong, and access to non-judgmental treatment may be limited, that they may continue using. 

Medication for OUD (MOUD) with methadone or buprenorphine (aka Suboxone or Subutex), also referred to as MAT, is the standard of care in pregnancy and has been shown to reduce maternal mortality. However, our research has shown that MOUD is not consistently available to pregnant and postpartum people in U.S. jails due to funding, resource, and implementation challenges, as well as to stigma that this population faces.

There are unique medical, psychosocial, and structural considerations for providing MOUD to pregnant individuals. AND there are unique considerations to providing MOUD in jails. 

Enter MOMCARE. . . . MOMCARE is the first and only OUD guidance that is specifically tailored to both JAILS and PREGNANCY.

What’s the best treatment in pregnancy?

• The long-established medical standard of care for pregnant women who misuse opioids is to be on ongoing medication treatment for opioid use disorder (MOUD), also referred to as MAT, with methadone or buprenorphine, and to avoid going through withdrawal. There are many maternal and fetal benefits to MOUD in pregnancy, and many risks to withdrawal in pregnancy. 
• The reason for this is that opioid withdrawal in pregnancy is unsafe. Withdrawal is associated with high rates of return to use (also called relapse), with many risks to the pregnant person and baby.  On the flip side, being on MOUD in pregnancy is safe and improves outcomes for the mom and baby!

• We advocate for a “Medication First” approach (adapted from the Missouri Department of Mental Health):
  • Pregnant patients receive MOUD as quickly as possible, prior to lengthy assessments or treatment planning sessions.
  • Maintenance MOUD is delivered in pregnancy and postpartum without arbitrary tapering or time limits
  • Individualized psychosocial services are offered, but not required as a condition of MOUD treatment
  • MOUD is discontinued only if it appears to be worsening the patient’s condition or they, after thorough counseling, request to stop treatment.

• Behavioral health counseling is also an important part of OUD treatment in pregnancy. However, even MOUD alone is beneficial. Someone needs to be feeling physically stable without cravings in order for them to be fully engaged in counseling. MOUD should never be withheld if someone declines counseling, or if your jail doesn’t have access to counseling. 
• Methadone and buprenorphine are both safe and effective in pregnancy. Choosing which medication to start should be an individualized decision based on the patient and on local availability of providers. 

How effective is buprenorphine? 

• In a large recent study, treating just 20 pregnant people with buprenorphine prevented 1 serious complication, like preterm birth, NICU admission, severe maternal illness, or death.
• For comparison, we treat about 50 people with aspirin to prevent 1 heart attack.  
• Buprenorphine has a bigger impact than many other treatments we rely on for other health conditions! Buprenorphine works - and it’s worth fighting to make sure pregnant people can access it! 

What are the basic steps jail staff should take when a pregnant woman with OUD comes to jail?

See the MOMCARE Initial Pregnancy & OUD Screening and Care at Jail Intake algorithm.

Pregnant women with OUD should be a priority for evaluation and referral!

SCREEN! To know who needs treatment, jails should screen for both pregnancy and opioid use at intake.

CONTINUE MOUD/MAT! If a pregnant patient comes into your jail and she is already receiving methadone or buprenorphine from a community provider, the jail must continue this medication while in custody.

START MOUD/MAT AND MANAGE WITHDRAWAL SYMPTOMS!

• If a pregnant patient with OUD comes into your jail and is not already on treatment, then they must be assessed for withdrawal risk and referred to start treatment with methadone or buprenorphine. Treatment should be started ideally within 24 hours. 
• For most patients and most jail settings, this should happen off-site at a hospital that has obstetrical capacity. However, there may be jails that have the capacity for on-site pregnancy MOUD initiation and withdrawal management. 
• These patients should receive judgment-free counseling about the risks and benefits of MOUD in pregnancy, and the risks of withdrawal in pregnancy. Some pregnant women may be hesitant to start MOUD because they are afraid it might harm their fetus, or because they have heard the baby might go through opioid withdrawal after birth (“NAS” or “NOWS”). While some babies do have withdrawal symptoms, this is an expected, treatable, short-term condition. Also, it can happen even if the mom was not on MOUD in pregnancy. 
• While waiting to start MOUD, or if a pregnant patient declines MOUD, she should still have her withdrawal symptoms treated with medications (most medications used for withdrawal symptoms are safe in pregnancy), and she should be closely monitored for any warning signs that require a higher level of care. 

SHOW COMPASSION! Jail staff interacting with pregnant women with OUD should be sensitive to the overlapping stigma and judgement that pregnant patients who are incarcerated and who use substances experience.

CONTINUE MOUD/MAT TREATMENT during incarceration (unless the patient requests to stop).

What are other pregnancy-specific OUD treatment considerations?

• Methadone and buprenorphine doses usually have to be increased as pregnancy progresses, because of physiologic changes in how pregnant women clear medications. 
• Many pregnant women with OUD, especially those in jail, are nervous about what will happen when they go into labor and after they give birth. They should receive counseling about pain management options during labor, and what to expect for their baby after delivery. 
• Breastfeeding is safe and recommended for women on MOUD. That may seem hard for people going back to jail, but it is doable!
• Most states have laws that prohibit the use of restraints on pregnant women, especially during labor and delivery. Jails must comply with these laws, whether taking a pregnant patient off-site for a methadone dose or in labor at the hospital. 
• There are many urgent warning signs in pregnancy, whether or not someone has OUD, that can be signs of dangerous conditions—things that wouldn’t be so concerning in a non-pregnant patient. Jail staff should be prepared to recognize these basic warning signs. 

POSTPARTUM OUD CARE

• MOUD must be continued even after the pregnant woman gives birth and is no longer pregnant. This is because the postpartum period is a very vulnerable time for overdose death. Also, OUD is a chronic disease that requires long-term treatment.
• MOUD doses usually need to be adjusted postpartum.

There is a lot of information on MOMCARE! Different people will find different parts of it useful and will use it in different ways. See this 1-pager that synthesizes the information below on MOMCARE and how to use it. 

What is MOMCARE?

MOMCARE is designed for people working in and leading jails to help support them as they care for and implement services for pregnant patients with OUD who are in their facility.  You can use MOMCARE in the moment when you have a new pregnant patient with OUD in front of you to know the key steps of what you should do, and you can use MOMCARE to learn more about the topic and best practices.

MOMCARE is a combination of new, evidence-based materials specific to OUD in pregnancy in jails that our team has created and links to a few existing key resources that we have vetted.

Note that MOMCARE is intended to provide key information and guidance for jail staff, but it is NOT intended to give staff the expertise of addiction specialists or Ob/Gyn’s. That would be asking a lot! Therefore, we do not provide a detailed protocol in our clinical guidance on methadone or buprenorphine doses for induction in pregnancy—that is for your expert consultants/providers to do. And, we do not expect jail staff to diagnose when someone is in labor—but they do need to know when a pregnant patient should be evaluated for labor. That is the kind of guidance MOMCARE provides.

There are many challenges to providing this care, but we also know it’s possible! We hope to provide clinical and implementation guidance to ensure jails are equipped to provide evidence-based, life-saving care to pregnant and postpartum people with OUD in and leaving jail—whether they see 50 patients a year or 1!

How to Use MOMCARE

MOMCARE is divided into 2 main sections: direct care and services for pregnant patients with OUD in jail (“Pregnancy OUD Care”), and how get systems and plans in place so that your jail can provide the necessary care for these patients (“Implementation”), whether that’s a comprehensive program onsite or knowing whom to call and where to obtain an MOUD (also referred to as MAT) dose when a pregnant patient comes through.

• The Pregnancy OUD Care menu has 9 sections- Screening, Initial Care, Custody Guidance, Ongoing Care, When to Transport, Reentry Planning, Labor & Birth, Postpartum Care and Breastfeeding, and Guardianship and Infant Placement. Each of these sections is organized with 3 tabs- “Key Points," Deeper Dive," and “Resources.” Within the Key Points and Deeper Dive, content is broken into "How," "Why," and "Keep in Mind." If you just want to know what to do, go to “How?” If you want to learn the evidence and rationale, go to “Why?”. If you just want resources. . . You get the idea!
• The Implementation menu has 10 sections-  Program Implementation, MOUD/MAT Delivery, Pregnancy & Postpartum Care, Staff Training, Legal and Regulatory, Reentry and Transitions of Care, Behavioral Health and Peer Support, Working with Community Partners, Technical Assistance, and, Data Collection. Each of these sections is organized with 3 tabs- “Key Points," Deeper Dive," and “Resources.”

When you see the 🤰 symbol, that means that this is content that is specific to caring for pregnant patients.

FAQs have answers to some of the most common questions about caring for pregnant patients with OUD in jail.

The Resources page has a few key resources of tools we have created and guides we recommend. Each section of the Pregnancy OUD Care and Implementation menus on MOMCARE also has a Resources tab that contains more detailed resources.

You can also use the Search bar at the top to find answers to your questions.

You can use MOMCARE on a computer or your phone, in real-time when taking care of a patient or during downtime when you want to learn about a particular area, either as an individual or as a group as part of an in-service or training.

If your staff do not have easy access to the internet while they are interacting with pregnant patients, then you might want to PRINT out some of the key resources we have created, such as the Initial MOMCARE Pregnancy & OUD Screening and Care at Jail Intake algorithm, or the  MOMCARE Preparing for Reentry Checklist for Pregnant and Postpartum Patients. We also recommend printing out this diagram on Urgent Maternal Warning Signs and hanging it in housing units, intake, and clinical areas. You can also print the content from any of the website pages.

If you are a . . . then . . .

• Jail clinical provider, then you will most often use Pregnancy OUD Care> Screening, Initial Care, Ongoing Care, Labor & Birth, and Postpartum Care.
• Jail mental health provider, then you will most often use Pregnancy OUD Care>Ongoing Care, Reentry Planning, Postpartum Care
• Case Manager, Social Worker, and Program Coordinator, then you will most often use Pregnancy OUD Care>Reentry Planning, Guardianship and Infant Placement.
• Custody Officer, then you will most often use Pregnancy OUD Care> Custody Guidance, Screening, Initial Care, Labor & Birth.
• Administrator (custody or medical), Program Coordinator then you will most often use Implementation.

Our implementation guidance gives you key points and is tailored to pregnancy MOUD (also referred to as MAT) in jail. For a detailed, step-by-step MOUD implementation plan (not specific to pregnancy), we recommend this Implementation Toolkit from Vital Strategies/National Council on Behavioral Health. However, it does not reflect the updates to the DEA/SAMSHA rule on providing methadone in correctional facilities. See MOMCARE MOUD/MAT Delivery Models for more details. 

This is what ideal care for pregnant women with OUD entering and leaving jails should look like:

• Access to continue and start methadone and buprenorphine. 
• Non-judgmental behavioral health and other counseling that is specific to pregnancy and parenting concerns.
• Prenatal care by a qualified provider.
• Re-entry services linking them to MOUD providers in the community, housing support, and prenatal care. 

The MOMCARE team is well aware that this ideal takes a lot of steps to get there—and in some settings getting access to both methadone and buprenorphine may not ever be practically achievable.

We also know that some jails may only see 1 pregnant patient with OUD a year. It may not be practical to have a whole program set up for them, but you still need systems in place to provide the right care. Don’t worry! We’ve got you covered too.

MOMCARE’s implementation resource bundle provides you with a menu of options for various categories of infrastructure and procedures so that you can choose which option works best for your jail’s capacity and community setting. Some of these menu categories are specific to services for pregnant and postpartum patients, while some apply to MOUD for all patients in your jail. We provide menu options and other

implementation options in the following areas:

In addition, we also provide guidance on which areas you should focus on if your jail is just starting with MOUD pregnancy services if you have some services and are enhancing them, or if you have a lot in place and are making improvements.

• Beginner: Limited availability of MOUD in pregnancy, such as none at all or only able to continue one MOUD medication if they were on it pre-jail, but do not start any pregnant patient on MOUD. Staff have limited knowledge of pregnancy-specific issues. Limited reentry and community linkage systems are in place for pregnant patients. 
• Intermediate: Jail allows pregnant patients to continue both methadone and buprenorphine, but does not initiate, or allows continuation and initiation of only one medication. Staff have limited knowledge of pregnancy-specific issues. Jail does not continue MOUD postpartum. Some reentry and community linkages are in place for pregnant patients.
• Advanced: Jail provides access to continue and initiate methadone and buprenorphine in pregnancy, and continues postpartum. Jail staff may have some knowledge of pregnancy-specific issues. Some reentry and community linkage systems are in place for pregnant patients. 

Words matter. The ways that jail staff communicate with pregnant patients in custody who use opioids can have a big impact on their willingness to be in treatment. In general, pregnant patients with OUD experience judgment from others for using substances while pregnant and have histories of trauma. Communication that conveys judgment and stigma, even if unintentional, leads to feelings of shame and prevents pregnant patients from seeking prenatal care and substance use recovery services. Thus, patient interactions should be non-judgmental, trauma-informed, and person-centered.

“So when I went there [jail] and I got these people [jail staff] looking at me like I didn't even try or, like, I didn't even care, and I'm sitting there already crying asking them what else can they do? I don't want to lose my kid and all I get told is, well, you should have thought about that. Like they just - they talked to me like I was dirt under their feet. And it really hurt; like, it was devastating. It makes - it literally makes you not even want to tell nobody that you're on drugs or you're pregnant. You just want to go out and do what you got to do because you know at least you're not being looked at like that. You're not being talked to like that.”—MOMCARE study participant who was pregnant in jail with OUD

Here are some sample scripts that MOMCARE has developed for this population:

• Screening pregnancy
• Screening OUD
• Counseling for MOUD/MAT in pregnancy
• Screening other substance use

Here are some best practices, tips, and resources for interacting with pregnant patients with OUD in custody:

• Treat people with basic dignity and respect.
  • Greet them with standard pleasantries, call them by their name, make eye contact, and use a kind tone. “Good morning, Ms. Smith, how are you feeling today?”
• Familiarize yourself with the impact of trauma. Avoid perspectives like “what is wrong with you?” and instead use the perspective of “what happened to you?”
• Educate yourself about addiction. Addiction is a medical condition with a biological (and also behavioral) basis. It is not a moral failing.
• Think about the language you use when speaking about addiction. Check out this table on person-centered words to use regarding pregnancy and drug use.
• Verbally communicate with patients before handling them, touching them, or doing procedures on them. Ask, and wait, for permission.
• Be a good listener. Listen without judgment or expectations. Use active listening strategies—nodding your head, validating phrases like “That must be hard for you”, and avoid interrupting.
• Involve patients in their care plan and ask for feedback or concerns.
• Be aware of your body language and other non-verbal cues.
• Incorporate an approach of cultural humility.
  • Cultural humility involves a lifelong commitment to self-evaluation where you recognize that patients may have cultural backgrounds and values that are different than yours and that as correctional health and custody professionals, we must start with examining our own beliefs and cultural values.
• Use an intersectionality lens that recognizes people’s social and political identities (e.g. race, gender, sexuality, etc.) can lead to a combination of unique privileges and disadvantages.

Here are some training and other resources to facilitate person-centered interactions with pregnant patients and those who use opioids. See MOMCARE Staff Training: Stigma and Judgment for more details.

• MOMCARE table on Non-stigmatizing Language for Pregnancy and Addiction
• Patient-Centered Communication Tips: Basic skills for communicating with patients in a clinical setting
• 10 Tips for talking about addiction
• Beyond Labels (March of Dimes, 2024)- 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.
• 10 Things Pregnant and Parenting Women Who Use Substances Would Like Practitioners to Know (p.16)
• A 90-minute webinar on Integrating a Trauma-informed Approach into Substance use Disorder Treatment

Review the urgent maternal warning signs and educational materials on being pregnant/postpartum with OUD with patients. Educate your patients about these symptoms so they are aware while in jail and in the community. 

MOMCARE Glossary

ACOG: American College of Obstetricians and Gynecologists. A national professional society that sets medical standards for care in pregnancy and postpartum.

Addiction: A colloquial, non-medical term often used as shorthand for a substance use disorder (see below)

Alcohol Use Disorder (AUD): Substance use disorder involving alcohol (sometimes called “alcoholism” or “alcohol addiction”). Alcohol withdrawal can be medically dangerous.

Algorithm: An ordered set of steps to be followed in a specific circumstance

Behavioral Health Service: Trained counselors provide non-judgmental counseling and support to individuals along their recovery journey. Help guide them in recognizing patterns in behaviors that sustain the substance use disorder and develop skills and strategies to aid their recovery. Counseling can be individual or group. 

Benzodiazepines (“benzos”): Sedative drugs commonly prescribed for anxiety (such as Xanax/alprazolam, Ativan/lorazepam, Klonopin/clonazepam). Benzodiazepine withdrawal can be medically dangerous.

Buprenorphine: An FDA-approved medication used to treat OUD. It is a synthetic opioid that partially binds and partially blocks (agonist/antagonist) the opioid receptor. Formulations include buprenorphine tablet (Subutex); buprenorphine/naloxone tablet (Zubsolv); buprenorphine/naloxone film (Suboxone, Cassipa, Bunavail); buprenorphine injection (Sublocade, Brixadi); and buprenorphine implant (Probuphrine). Injectables and implants are not recommended in pregnancy. 

Child Protective Services (CPS): A group of agencies and institutions authorized by law to intervene in families, remove children from their parents temporarily or permanently, terminate parental rights, and place children in foster care. While not all CPS interventions result in children being removed from their parents, any parental interaction with CPS can result in legal consequences. When someone gives birth while incarcerated, hospital staff will often notify CPS to evaluate a plan of safe care for the infant. Pregnant people who use substances are more likely to have their child removed by CPS even though many people who use substances can provide safe and loving care for their children when properly supported. CPS is also sometimes referred to as the “Department of Family Services” or “Child Welfare System.”

Doula: A trained, non-medical professional who provides physical and emotional support and information to pregnant individuals during childbirth as well as during pregnancy and postpartum. A growing number of jails have partnered with local doulas to provide support services to incarcerated pregnant patients. 

Drug Enforcement Agency (DEA): Federal law enforcement agency under the U.S. Department of Justice that enforces laws and regulations around controlled substances in order to promote safety and reduce illicit drug trafficking and use. There are specific DEA regulations around prescribing, dispensing, and storing MOUD that correctional facilities must adhere to.

Fentanyl: Pharmaceutical fentanyl is a synthetic opioid, approved for treating severe pain, typically advanced cancer pain. It is 50 to 100 times more potent than morphine. However, illegally made fentanyl is sold through illicit drug markets for its heroin-like effect, and it is often mixed with heroin or other drugs, such as cocaine, or pressed in to counterfeit prescription pills.

Gestational Age:How far along someone is in pregnancy. Usually expressed in weeks or months. Full pregnancy duration is defined as 40 weeks. Term pregnancy is ≥ 37 weeks. Preterm pregnancy is ~23-24 weeks-36 weeks and 6 days. Pre-viable pregnancy is less than 23-24 weeks and means the fetus could not survive outside the womb.   

Harm Reduction: A set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Harm reduction accepts that substance use is going to occur and includes safer use, managed use, and meeting people who use drugs “where they’re at,” while also supporting those who are interested in achieving abstinence, without imposing it on those who are not.  Examples include providing naloxone (Narcan) upon release from jail to prevent overdose and fentanyl test strips to check drug supply.

Intoxication: State involving clear dysfunctions in physical coordination, cognitive abilities, and/or mood.

Infant placement: Refers to the process of making a caregiver arrangement for the infant if a pregnant individual gives birth while in custody. It includes facilitating conversations with other family members or trusted friends, coordinating with social services, and making sure the designated caregiver is prepared to pick the infant up from the hospital. See Guardianship and Infant Placement for more details. 

Lactation: The process of producing and releasing milk from the breasts after giving birth. Can also occur after a miscarriage or abortion.   

Medication-Assisted Treatment (MAT): FDA-approved medications to treat a substance use disorder, used in combination with clinically indicated behavioral or cognitive-behavioral counseling and other indicated services. Also referred to as MOUD (see below) to acknowledge that the medications are not there to assist behavioral treatment, but rather that medication treatment is effective on its own.   

Medications for Opioid Use Disorder (MOUD): FDA-approved medications that are used to treat OUD, including formulations of buprenorphine, methadone, and naltrexone. MOUD is also sometimes referred to as “MAT” (medication-assisted treatment), however, MOUD terminology acknowledges a medication-first approach for the effective treatment of OUD. While the behavioral health counseling that is part of MAT is important,  medication alone is effective for the treatment of OUD. Once someone is stabilized on a dose of medication, they should be strongly encouraged to engage in behavioral health treatment as well. However, this should not be a requirement to be on MOUD/MAT.

Methadone: An FDA-approved, long-acting opioid medication used to treat OUD. It is a synthetic opioid that binds fully to the opioid receptor (agonist). 

Naloxone (Narcan): Short-acting opioid blocker that can reverse an opioid overdose if used in time.

Naltrexone (Vivitrol): An FDA-approved, injectable medication that blocks the opioid receptor (antagonist) used to treat OUD. It is NOT recommended during pregnancy.

Neonatal Abstinence Syndrome (NAS) A set of withdrawal symptoms that may occur in a newborn who was exposed to certain substances in utero; when there has been opioid exposure, it is also known as neonatal opioid withdrawal syndrome (NOWS). NAS/NOWS can occur with exposure to illicit opioids or  MOUD treatment. It is an expected, short-term, treatable side effect of a pregnant person being on evidence-based treatment. Not all infants exposed to MOUD will experience NAS/NOWS. Treatment of neonatal symptoms is both non-pharmacologic (“eat, sleep, console” protocols) and pharmacologic. 

Opioid: Natural, synthetic, or semi-synthetic chemicals that interact with opioid receptors on nerve cells in the body and brain and reduce the intensity of pain signals and feelings of pain. This class of drugs includes the illegal drug heroin, synthetic opioids such as fentanyl, and pain medications available legally by prescription, such as oxycodone, hydrocodone, codeine, morphine, and many others. Prescription opioids are generally safe when taken for a short time and as directed by a doctor, but because they produce euphoria in addition to pain relief, they can be misused and have addiction potential.Opioids such as methadone and buprenorphine are used to treat opioid use disorder.

Opioid Use Disorder (OUD): A problematic pattern of taking opioids that causes significant impairment or distress. An official diagnosis of OUD is based on specific, established criteria such as unsuccessful efforts to cut down or control use, or use resulting in social problems and a failure to fulfill obligations at work, school, or home, among other criteria. Opioid use disorder is preferred over other terms with similar definitions, “opioid abuse or dependence” or “opioid addiction.” In MOMCARE, we use OUD  to signal both opioid misuse (see below) and someone who meets the full criteria for OUD.

Opioid Misuse: The use of illegal drugs and/or the use of prescription drugs in a manner other than prescribed, such as use in greater amounts, more often, or longer than told to take a drug, or taking someone else’s prescription, even if for a legitimate medical complaint such as pain; or taking a medication to feel euphoria (i.e., to “get high”).

Naloxone: A drug that can reverse the effects of opioid overdose and can be life-saving if administered in time. The drug is sold under the brand name Narcan or Evzio and comes as an injection or nasal spray. 

Overdose: Injury to the body (poisoning) that happens when a drug is taken in excessive amounts. Opioid overdose stops a person from breathing. An overdose can be fatal or, if reversed with naloxone, nonfatal.

Prescription drug monitoring programs (PDMPs): State or territorial-run electronic databases that track controlled substance prescriptions. PDMPs help providers identify patients at risk of opioid misuse, opioid use disorder, and/or overdose due to overlapping prescriptions, high dosages, or co-prescribing of opioids with benzodiazepines.

Peer Support: Peer support encompasses a range of activities and interactions between people who share similar experiences of being diagnosed with mental health conditions, substance use disorders, or both. Peer support offers a level of acceptance, understanding, and validation not found in many other professional relationships. By sharing their own lived experience and practical guidance, peer support workers help people to develop their own goals, create strategies for self-empowerment, and take concrete steps towards building fulfilling, self-determined lives for themselves.

Perinatal/Peripartum: Time during pregnancy, birth, and up to one year after birth.

Plan of Safe Care (POSC): A plan to address the needs of the parent and child.  The POSC may involve a range of short-term infant care arrangements, from the infant going to a family member while the parent engages in treatment, the infant being in the care of the mother/birthing parent (not if the patient is in jail custody), to placement in foster care.  It also often includes SUD treatment plans and other recommended or required services. The POSC can (and should) be started by any member of the patient’s care team before delivery–having a POSC already drafted can demonstrate the parent’s efforts to engage in treatment and strengthen their support system.

Postpartum: The time immediately after birth and up to 12 months following birth

Pregnant Person: Any person, regardless of gender, who is currently pregnant. We have used “pregnant person” throughout MOMCARE because it is a gender-inclusive term that recognizes the needs of transgender and non-binary people who can also become pregnant, and who therefore also require compassionate pregnancy-related care.

Prenatal/antepartum: Time from pregnancy to birth

Provider: A medical doctor or advanced practice clinician, including a certified nurse midwife, nurse practitioner (NP), or physician assistant (PA) who is trained and licensed to deliver clinical care. Also called clinician.

Qualified perinatal care provider A provider who has received specialty training in care of pregnant and postpartum patients. This generally includes Ob/Gyn and family medicine physicians, certified nurse midwives, and NPs or PAs who have received obstetrics training.

Qualified health care professional: A medical doctor, nurse, nurse practitioner, physician assistant, or other credentialed, experienced, and licensed clinician. 

Screening: Asking 1 or more questions about substance use to identify people who have unhealthy substance use/misuse and who are at risk for withdrawal from substances. This is different than “testing,” which is using a biologic sample like urine, blood, or saliva to detect the presence of substances in the body.  There are several validated screening questionnaires for pregnant patients.

Stigma: A set of negative and often unfair beliefs that society or a group of people have about something. Stigma related to pregnant people with OUD who are in jail includes discrimination and labeling them as an addict, a bad parent, or someone who does not care about their pregnancy and/or child. Stigma discourages pregnant individuals with OUD from seeking help, prenatal care, and substance use treatment. See Staff Training on Stigma and Judgement. 

Stimulant: Substances that speed up the body’s systems (such as amphetamines, caffeine, cocaine, diet pills, methamphetamine, or “bath salts”)

Substance Abuse and Mental Health Services Administration (SAMHSA): Federal agency within the Department of Health and Human Services. SAMHSA makes substance use disorder and mental health information, services, and research accessible to the public. Provides many resources on locating treatment providers, best practices, and more.

Substance Use Disorder (SUD): Mental health diagnosis indicating continued substance use despite significant negative consequences; requires medical management and support

Taper: Gradual reduction of medication dosage over time under medical supervision. Tapering is used to prevent the harmful effects of rapidly withdrawing alcohol, benzodiazepines, opioids, and other substances.

Trafficking: The recruitment, transportation, transfer, harboring or receipt of people through force, fraud, or deception, to exploit them for profit. Tracking can take many forms, but women who use drugs are often victims of sexual exploitation which is a person profiting from the use of another person's body in a sexual manner to benefit (financially or otherwise). 

Trauma-informed Care: Care that acknowledges people’s behaviors, coping mechanisms, and current life circumstances are often due to prior traumatic experiences such as sexual, physical, and emotional abuse, justice system exposure, and systemic racism. Understanding a patient’s life experiences can improve patient engagement, treatment adherence, health outcomes, and provider and staff wellness. Key concepts include: 1) realizing the widespread impact of trauma and understanding potential paths to recovery; 2) recognizing the signs and symptoms of trauma; 3) integrating knowledge about trauma into policies, procedures, and practices; and 4) seeking to actively resist re-traumatization. For instance, gynecologic exams and cavity searches can be especially traumatic for people with prior sexual abuse.

Unwell: Observed signs, symptoms, or indications by a layperson that (1) an individual may be sick (physically or psychologically); or, (2) in the case of a patient who has already been assessed by a qualified health care professional, the patient’s condition is worsening, becoming unstable, or becoming a danger to self or others. For a pregnant person, this also includes signs or symptoms of labor or urgent maternal warning signs, like vaginal bleeding, pelvic pain, severe headache, contractions, and other symptoms. Err on the side of caution! (adapted from the definition of unwell developed by the Bureau of Justice Assistance) See the BJA training video (7 mins) on how to identify if someone in jail is unwell. 

Urgent Maternal Warning Signs: Signs and symptoms that can occur during pregnancy and in the year after delivery that require immediate professional medical attention, as these signs and symptoms could indicate a life-threatening situation. These are signs and symptoms that may not be so worrisome in a non-pregnant/postpartum person, but may be signs of danger for those who are pregnant/postpartum. Warning signs include headache that won’t go away or gets worse over time; dizziness or fainting; vision changes; fever of 100.4 or higher; extreme swelling of hands or face; thoughts about harming oneself or their baby; trouble breathing; chest pain or fast-beating heart; severe nausea and throwing up; severe belly pain that doesn’t go away; baby’s movement stopping or slowing during pregnancy; vaginal bleeding or fluid leaking during pregnancy; vaginal bleeding or discharge after pregnancy; severe swelling, redness or pain in the leg or arm; overwhelming tiredness.  

Urine Drug Test: An immunoassay test performed on a urine sample that tests for the presence of certain drugs of abuse in a person’s system. Some substances stay in the system longer than others. National guidelines recommend screening questions, not a urine drug test, to assess for unhealthy substance use in pregnancy. When a urine test is performed during pregnancy, patients must be informed of the implications and give their verbal consent.

Validated: A reliable tool or practice that has been deemed scientifically sound through research studies. 

Withdrawal Syndrome: Characteristic physical and psychological consequences of rapidly decreasing or ceasing the use of a given substance. Withdrawal can involve agitation, confusion, dehydration, delirium, diarrhea, disorientation, hallucinations, seizures, vomiting, and other medical symptoms that can cause serious harm or death. 

*Some definitions have been reproduced or adapted from the following publicly available sources:

Centers for Disease Control and Prevention, Opioid Basic Terms;

Guidelines for Managing Substance Withdrawal in Jails (BJA); SAMHSA

Clinical Guidance for Treating Pregnant and Parenting Women with Opioid Use Disorder and their Infants ; SAMHSA

Key Ingredients for Successful Trauma-Informed Care Implementation ; National Harm Reduction Coalition

Principles of Harm Reduction; National Harm Reduction Coalition

Pregnancy and Substance Use: A Harm Reduction Toolkit; Columbia Journal of Race and Law,

Strengthened Bonds;SAMHSA

Peer Support