A COLLABORATIVE 

APPROACH TO THE 

TREATMENT OF 

PREGNANT WOMEN 

WITH OPIOID USE 

DISORDERS

Practice and Policy Considerations for Child Welfare, 

Collaborating Medical, and Service Providers
This page is intentionally left blank
A Collaborative Approach to the 

Treatment of Pregnant Women With 

Opioid Use Disorders

Practice and Policy Considerations for 

Child Welfare, Collaborating Medical, 

and Service Providers

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

and

Administration for Children and Families

Administration on Children, Youth and Families

Children’s Bureau
i

Acknowledgments

This report was prepared by the National Center on Substance Abuse and Child Welfare (NCSACW) 

under contract number HHSS270201200002C for the Substance Abuse and Mental Health Services 

Administration (SAMHSA) and the Administration for Children and Families (ACF) of the U.S. 

Department of Health and Human Services (HHS). Sharon Amatetti, M.P.H., served as the author and 

government project officer from SAMHSA; Elaine Stedt, M.S.W., served as the project officer for the 

Children’s Bureau of ACF; Nancy K. Young, Ph.D., served as the author and project director from the 

NCSACW; and Kari Earle, M.Ed., and Erin Hall, M.S.O.T., served as the authors from the NCSACW.

Disclaimer

The views, opinions, and content of this publication are those of the authors and do not 

necessarily reflect the views, opinions, or policies of SAMHSA or HHS. The content of this 

publication does not constitute legal advice and should not be construed or relied upon as legal 

advice. Consultation with an attorney concerning confidentiality and child abuse and neglect 

reporting requirements is strongly recommended.

Public Domain Notice

All material appearing in this publication, except those taken from copyrighted sources, are in the 

public domain and may be reproduced or copied without permission from SAMHSA. Citation of 

the source is appreciated. However, this publication may not be reproduced or distributed for a fee 

without the specific, written authorization of the Office of Communications, SAMHSA, HHS.

Electronic Access and Printed Copies

This publication may be downloaded or ordered at http://store.samhsa.gov. A phone order may 

also be placed, in English or Spanish, by calling SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727).

Recommended Citation

Substance Abuse and Mental Health Services Administration. A Collaborative Approach to the 

Treatment of Pregnant Women with Opioid Use Disorders. HHS Publication No. (SMA) 16-4978. 

Rockville, MD: Substance Abuse and Mental Health Services Administration, 2016. Available at: 

http://store.samhsa.gov/.

Originating Office

Division of Systems Improvement, Center for Substance Abuse Treatment, Substance Abuse and 

Mental Health Services Administration, 5600 Fishers Lane, Rockville, MD 20857.

HHS Publication No. (SMA) 16-4978
ii

Table of Contents

Acknowledgments ........................................................................................................................ i

Introduction................................................................................................................................ 1

Background ................................................................................................................................. 3

Scope of the Problem ................................................................................................................... 5

Opioid Use Trends .............................................................................................................................5

Neonatal Abstinence Syndrome .......................................................................................................6

Guidelines for Supporting Collaborative Policy and Practice .......................................................... 8

Existing Guidelines ...........................................................................................................................8

Need for Collaboration Among Multiple Agencies ........................................................................... 11

Comprehensive Framework for Intervention ............................................................................... 16

Overview of Substance-Exposed Infants (SEI) Framework ............................................................... 16

A Guide for Collaborative Planning ............................................................................................. 18

Building the Collaborative Team ..................................................................................................... 19

Concluding Thoughts ................................................................................................................. 22

Appendix 1: Facilitator’s Guide ................................................................................................... 25

Appendix 2: Citations ................................................................................................................ 61

Appendix 3: Training Needs and Resources ................................................................................. 67

Appendix 4: Key Features of Medications Approved for Treating Opioid Use Disorders ................... 75

Appendix 5: Children and Recovering Mothers (CHARM)

Collaborative in Burlington, Vermont: A Case Study .................................................................... 81

Attachment A: CHARM Collaborative Memorandum of Understanding ..........................................103

Attachment B: CHARM Collaborative Release of Information .........................................................107

Attachment C: Hub and Spoke Initiative ........................................................................................111

Appendix 6: Additional Acknowledgments ................................................................................115
iii

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1

Introduction

This guidance publication is intended to 

support the efforts of states, tribes, and local 

communities in addressing the needs of 

pregnant women with opioid use disorders 

and their infants and families.1 National data 

show that from 2000 to 2009 the use of opioids 

during pregnancy increased from 1.19 to 5.63 

per 1,000 hospital births (Patrick, Schumacher, 

Benneyworth, Krans, McAllister, & Davis, 2012). 

Because of the high rate of opioid use and 

misuse among all women, including pregnant 

women, medical, social service, and judicial 

agencies are having to confront this concern 

more often and, in some communities, at 

alarming rates.

Opioids are drugs that reduce the intensity 

of pain signals. The term “opiates” refers only 

to natural opium derivatives, and the term 

“opioids” refers to drugs that activate opioid 

receptors, including opiates, heroin, and 

synthetic opioids (e.g., certain prescription 

painkillers, such as oxycodone) (CSAT, 2004).

Data from SAMHSA’s National Survey on 

Drug Use and Health show that between 

2007 and 2014, the numbers of past-year 

heroin initiates, heroin users, and people with 

heroin dependence increased significantly 

(SAMHSA, 2015). The pattern of initiating 

heroin use has changed over the past decade. 

Approximately three-quarters of persons who 

use heroin report prior non-medical use of 

prescription opioids, as well as current abuse or 

dependence on additional substances such as 

stimulants, alcohol, and marijuana. Conversely 

a small percentage, approximately four percent, 

of persons with non-medical use of prescription 

drugs initiate heroin use. However given the 

1 According to the U.S. National Library of Medicine, the term “infant” is used to describe a child from newborn to 1 year 

(http://www.nlm.nih.gov/medlineplus/ency/article/002004.htm), and the term “newborn” (neonate) is used to describe an 

infant who is 4 weeks old or younger (http://www.nlm.nih.gov/medlineplus/ency/article/002271.htm). For the purpose of this 

document, these definitions are applied.

2 “What is the Federal Government Doing to Combat the Opioid Abuse Epidemic?” Statement of Douglas C. Throckmorton, 

M.D., Deputy Director for Regulatory Programs, Center for Drug Evaluation and Research, Food and Drug Administration, 

Department of Health and Human Services before the Subcommittee on Oversight and Investigations, Committee on Energy 

and Commerce, U.S. House of Representatives on May 1, 2015. http://www.fda.gov/newsevents/testimony/ucm446076.htm

10.3 million persons who reported non-medical 

use of prescription drugs in 2014, this small 

percentage of conversion to heroin generates 

several hundred thousand new heroin users 

(Compton, Jones & Baldwin, 2016).

When pregnant women use opioids, their 

infants may be affected. Neonatal abstinence 

syndrome (NAS) is the common term used 

to represent the pattern of clinical findings 

typically associated with opioid withdrawal in 

newborns (Hudak & Tan, 2012). However, the 

U.S. Food and Drug Administration (FDA) now 

uses the term “neonatal opioid withdrawal 

syndrome” on warning labels when referring to 

the maternal use of opioids during pregnancy.2

 

Most newborns of mothers who used opioids 

during pregnancy develop symptoms of NAS, a 

postnatal drug withdrawal syndrome, primarily 

caused by maternal opioid use (Patrick et al., 

2012). The range and severity of the symptoms 

experienced by the infant depends on a variety 

of factors, including the type of opioid the 

infant was exposed to and whether the infant 

was exposed to multiple substances. Treatment 

of NAS includes non-pharmacological and 

pharmacological methods. 

Abrupt discontinuation of opioid use during 

pregnancy can result in premature labor, fetal 

distress, and miscarriage. Medical withdrawal 

from opioids should be conducted under 

the supervision of physicians experienced in 

perinatal addiction (Kaltenbach, Berghella, & 

Finnegan, 1998). However, pregnant women 

who stop using opioids and subsequently 

relapse are at greater risk of overdose death. 

There is also an increased risk of harm to the 

fetus. Because NAS is treatable, medicationassisted treatment (MAT) is typically 

recommended instead of withdrawal or 

abstinence (Jones, O’Grady, Malfi, & Tuten, 2008).
2

The use of MAT during pregnancy is a 

recommended best practice for the care of 

pregnant women with opioid use disorders3

(American College of Obstetricians and 

Gynecologists Committee on Health Care for 

Underserved Women, & American Society of 

Addiction Medicine, 2012). MAT is the use of 

medications in combination with counseling 

and behavioral therapies to provide a wholepatient approach to the treatment of substance 

use disorders (SAMHSA, 2014a). Research 

shows that a combination of medication and 

behavioral therapies is most successful for 

substance use disorder treatment. MAT is 

clinically driven and focuses on individualized 

patient care.

Medications used to treat opioid use disorders 

include methadone and buprenorphine. Both 

of these medications stop and prevent opioid 

withdrawal and reduce opioid cravings, allowing 

the person to focus on other aspects of recovery. 

Like any medication given during pregnancy, the 

use of MAT in pregnant women has both risks 

and benefits to the mother and fetus. Therefore, 

MAT needs careful consideration by the pregnant 

women themselves as well as coordination by 

the providers and agencies that have influence 

and authority over this population of pregnant 

women and their infants.

To inform this guidance document, the 

National Center on Substance Abuse and 

Child Welfare (NCSACW), the Substance Abuse 

and Mental Health Services Administration 

(SAMHSA), and the Administration on Children 

and Families (ACF) formed a national panel 

of experts (listed in Appendix 6: Additional 

Acknowledgments). This panel identified the 

practice and policy considerations that each 

partner agency or organization needs to 

consider when working with, and on behalf of, 

pregnant women with opioid use disorders and 

their children. These experts met several times 

over six months in 2014.

3 The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders ([DSM-5] American Psychiatric Association, 2013) 

uses the term “opioid use disorder” to include abuse of or dependence on opioids. Previous editions of the DSM differentiated 

between the two categories. The DSM-5 combines abuse and dependence into a single disorder, measured on a continuum 

from mild to severe.

Panel members agreed that building 

knowledge, skills, and expertise within the 

healthcare (including obstetrics, pediatrics, 

substance abuse treatment, and mental 

health), child welfare, and judicial systems 

and tribal communities will enable these 

entities to better deliver coordinated services 

to this population of pregnant women and 

their families. This guidance document is 

designed to assist these systems in improving 

their collaborative practice and to provide 

information about additional resources that 

will strengthen their capacity to provide 

coordinated, best-practice care and services. 

The overarching message of this guide is 

that a coordinated, multi-system approach 

best serves the needs of pregnant women 

with opioid use disorders and their infants. 

Collaborative planning and implementation of 

services that reflect best practices for treating 

opioid use disorders during pregnancy are 

yielding promising results in communities 

across the country. Advance planning for 

the treatment of pregnant women with 

opioid use disorders that addresses safe care 

for mothers and their newborns can help 

prevent unexpected crises at the time of 

delivery. This guidance document provides 

background information on the treatment of 

pregnant women with opioid use disorders, 

summarizes key aspects of guidelines that have 

been adopted by professional organizations 

across many of the disciplines, presents 

a comprehensive framework to organize 

these efforts in communities, and provides a 

collaborative practice guide for community 

planning to improve outcomes for these 

families. A set of appendices provides details 

on implementing the recommendations in the 

guide as well as a summary of lessons from one 

community’s experience over the past decade.
3

Background

Opioid medications used to relieve pain 

are beneficial to many people but are often 

overprescribed.4 The overuse and misuse of 

these medications in the United States over 

the past decade has contributed to thousands 

of overdose deaths. According to the Centers 

for Disease Control and Prevention (CDC), 

from 1999 to 2010, yearly prescription opioid 

overdose deaths among women increased 

from 1,287 to 6,631 (CDC, 2013). These 

numbers represent a 400 percent increase 

over 10 years (see Scope of the Problem on 

page 5 for additional information). The use of 

heroin has also increased greatly over the last 

decade. Between 2007 and 2014, the numbers 

of past-year heroin initiates, heroin users, and 

people with heroin dependence has increased 

significantly (SAMHSA, 2015).

The use of MAT, in combination with counseling 

and behavioral therapies, and access to a range 

of supportive services, such as housing and 

employment services, assists the mother in 

achieving a more stable life (Newman & Kagen, 

1973; Finnegan, 1991; CSAT, 2005). In turn, it 

also stabilizes the intrauterine environment 

and avoids subjecting the fetus to repeated 

episodes of withdrawal, which places the 

fetus at higher risk for morbidity and mortality 

(Kaltenbach & Finnegan, 1998; Jones et al., 

2005; CSAT, 2005). According to the National 

Institute on Drug Abuse (NIDA):

“Methadone maintenance therapy (MMT) 

enhances an opioid-dependent woman’s chances 

for a trouble-free pregnancy and a healthy baby. 

Compared with continued opioid [use], MMT 

lowers her risk of developing infectious diseases, 

including hepatitis and HIV; of experiencing 

4

 The Office of Disease Prevention and Health Promotion has developed Pathways to Safer Opioid Use, a training resource that 

uses the principles of health literacy and a multimodal, team-based approach to promote the appropriate, safe, and effective 

use of opioids to manage chronic pain. http://www.health.gov/hcq/training.asp#pathways

pregnancy complications, including spontaneous 

abortion and miscarriages; and of having a child 

with challenges including low birth weight and 

neurobehavioral problems.

Along with these benefits, MMT may also 

produce a serious adverse effect. Like most 

drugs, methadone enters fetal circulation via 

the placenta. The fetus becomes dependent on 

the medication during gestation and typically 

experiences withdrawal when it separates from 

the placental circulation at birth. The symptoms 

of withdrawal, known as neonatal abstinence 

syndrome (NAS) include hypersensitivity and 

hyperirritability, tremors, vomiting, respiratory 

difficulties, poor sleep, and low-grade fevers. 

Newborns with NAS often require hospitalization 

and treatment, during which they receive 

medication (often morphine) in tapering doses 

to relieve their symptoms while their bodies 

adapt to becoming opioid-free.” (Whitten, 2012).

Methadone has been accepted as a treatment 

for opioid use disorders during pregnancy 

since the late 1970s (Kaltenbach & Finnegan, 

1998; Kandall et al., 1999; CSAT, 2005). In 

1998, a National Institutes of Health consensus 

panel recommended methadone maintenance 

as the standard of care for pregnant 

women with opioid use disorders (National 

Consensus Development Panel on Effective 

Medical Treatment of Opiate Addiction, 

1998). However, the use of buprenorphine 

for the management of opioid use disorders 

is becoming more widely used, with the 

emergence of data from randomized clinical 
4

trials that demonstrate its safety and efficacy 

(Jones et al., 2005; Fischer et al., 2006; Jones et 

al., 2010). Between 2005 and 2008, A National 

Institute on Drug Abuse (NIDA)-supported 

clinical trial, the Maternal Opioid Treatment: 

Human Experimental Research (MOTHER) 

study, examined the use of both methadone 

and buprenorphine maintenance therapy 

during pregnancy. Both medications are 

widely used to help individuals with opioid use 

disorders achieve stability and decrease illicit 

opioid use. The study also found that infants 

exposed to buprenorphine required shorter 

treatment duration and less medication to 

treat the symptoms of NAS and experienced 

shorter hospital stays when compared to 

infants exposed to methadone. No significant 

difference was found with respect to any 

serious maternal or neonatal adverse events 

(e.g., abnormal fetal health, neurological 

symptoms; Jones et al., 2010). 

Methadone and buprenorphine are classified 

as Pregnancy Category C5

 drugs by the FDA, 

meaning that adequate, well-controlled studies 

of how these drugs affect pregnant women 

are lacking. However, prescribing methadone 

or buprenorphine during pregnancy is not 

considered “off-label.” Choosing to proceed with 

methadone or buprenorphine treatment during 

pregnancy is an individual decision that women 

should make with their health care providers. 

Another medication used to treat opioid use 

disorders is naltrexone. Naltrexone functions 

as a pure opioid blocker; however, withdrawal 

can be induced if naltrexone is administered 

to an individual who is engaged in current 

opioid use. Thus, induction to naltrexone 

requires detoxification and an opioid-free 

period, which may lead to relapse vulnerability, 

re-establishment of physical dependence, 

increased risk behaviors, treatment dropout, 

and possible opioid overdose and death. 

There is insufficient research to support the 

use of naltrexone during pregnancy. When 

5

 In December 2014, the FDA published the Requirements for Pregnancy and Lactation Labeling Rule. The nomenclature is 

not used in the final rule, which requires the removal of the Pregnancy Categories A, B, C, D, and X from all human prescription 

drug and biological product labeling. Labeling is based on descriptive subsections for pregnancy exposure and risk, lactation, 

and effects to reproductive potential for females and males. Retrieved from http://www.gpo.gov/fdsys/pkg/FR-2014-12-04/

pdf/2014-28241.pdf (accessed August 19, 2015).

considering naltrexone use during pregnancy, 

the potential risk to the fetus should be 

given due consideration. Before research 

is conducted to determine the safety of 

naltrexone use during pregnancy, the benefits 

and risks must be carefully weighed (Jones, 

Chisolm, Jansson, & Terplan, 2013). Additional 

information on the use of methadone, 

buprenorphine, and naltrexone appears 

in Appendix 4: Key Features of Medications 

Approved for Treating Opioid Use Disorders. As 

more women using MAT during pregnancy 

give birth to newborns, the field is gaining 

knowledge about the typical withdrawal course 

that newborns experience, based on the types 

and doses of medications mothers are given 

to treat opioid use disorders as well as other 

aspects of their prenatal obstetrical care. 

Some distinctions among women who use 

opioids during pregnancy are paramount to 

understand because of care coordination for 

both mothers and infants. Although women 

who use opioids during pregnancy test positive 

for opioid use at the birth of their newborn, the 

supports and system responses should differ 

depending on whether or not the mother’s 

opioid use is medically managed. Generally, 

women who use opioids during pregnancy 

and/or at delivery can be categorized within 

one of the following groups: 

§ Are receiving pain management with 

medications under the care of a physician.

§ Are under the care of a physician and 

undergoing treatment for an opioid 

use disorder with medications, such as 

methadone or buprenorphine.

§ Are misusing or abusing opioid pain 

medications with or without a prescription 

(e.g., obtaining pills illegally for a nonmedical use, “doctor shopping,” obtaining a 

prescription illegally).

§ Are using or abusing illicit opioids, 

particularly heroin.
5

Women with opioid use disorders often 

face a host of complex and entwined 

issues. Although they may come from all 

socioeconomic backgrounds, their lives 

are complicated by psychosocial and 

environmental factors. Often, there is a history 

of sexual abuse and/or interpersonal violence, 

inadequate social supports, unpredictable 

parenting models, poor nutrition, unstable 

housing, and co-occurring psychiatric 

conditions. Pregnant women with opioid use 

disorders are likely to use multiple substances 

during pregnancy, including tobacco and 

alcohol. Fetal Alcohol Spectrum Disorders 

(FASD) is a term used to describe the range 

of conditions, including physical, mental, 

and behavioral conditions as well as learning 

disabilities, that can be experienced by an 

individual prenatally exposed to alcohol.6

Infants prenatally exposed to multiple 

substances are at risk for developing a 

wide spectrum of physical, emotional, and 

developmental problems. Exposure to multiple 

substances can affect an infant’s withdrawal 

symptoms. Other factors that can affect the 

infant’s withdrawal symptoms include the type 

of opioid that the mother used, whether the 

mother’s opioid use disorder was medically 

managed, and whether she received routine 

prenatal care. The hospital environment

itself, such as the methodology used to treat 

the infant’s withdrawal symptoms is also 

an important factor that can reduce or 

exacerbate the infant’s withdrawal (see the 

section on Neonatal Abstinence Syndrome for 

additional information). 

6

 Resources for FASD include (1) the CDC website (http://www.cdc.gov/ncbddd/fasd/facts.html) and (2) the FASD Center for 

Excellence (http://fasdcenter.samhsa.gov).

Scope of the Problem

Opioid Use Trends

Rates of prescription opioid pain medication 

use vary across regions of the country and 

among subpopulations. From 2000 through 

2013, the rate of overdose deaths related to 

heroin increased across all regions—11-fold in 

Growing concerns about the 

substantial increase in the number 

of pregnant women and newborns 

who test positive for opiates, coupled 

with the overwhelmingly inaccurate 

and alarmist reporting by the popular 

media regarding this issue, prompted 

more than 50 leading national and 

international researchers and experts 

to release an open letter to the media 

and policy makers in March 2013. In 

an effort to counter misinformation 

about pregnant women and 

prescription opioid use, these experts 

noted the following: 

Newborn babies are NOT born 

“addicted” and referring to newborns 

with NAS as “addicted” is inaccurate, 

incorrect, and highly stigmatizing. 

Portraying NAS babies as “victims” 

results in the vilification of their 

mothers, who are then viewed as 

perpetrators, and further perpetuates 

the criminalization of addiction.

Using pejorative labels such as

 “oxy babies,” “oxy tots,” “victims,” 

“tiny addict,” or “born addicted” 

places these children at substantial 

risk of stigma and discrimination 

and can lead to inappropriate child 

welfare interventions. 

NAS is treatable and has not 

been associated with long-term 

adverse consequences.

Mischaracterizing MAT as harmful and 

unethical contradicts the efficacy of 

MAT and discourages the appropriate 

and federally recommended 

treatment for opioid use disorder.

— International Drug Policy 

Consortium, 2013 
6

the Midwest, more than 4-fold in the Northeast, 

more than 3-fold in the South, and doubled in 

the West (Hedegaard, Chen, & Warner, 2015). 

As the opioid crises emerged, by 2008 the 

states with the highest rates of opioid-related 

morbidity and mortality were concentrated 

in the Appalachian region (e.g., Kentucky, 

West Virginia, and Ohio) (Behavioral Health 

Coordinating Committee [BHCC], 2013). States 

vary a great deal in rates of: (1) non-medical 

use of opioid pain medications, (2) prescriptions 

for opioid pain medications, and (3) drug 

overdose deaths (Centers for Disease Control 

and Prevention, 2013). States with lower rates of 

non-medical use of and prescriptions for opioid 

pain medications also had lower rates of drug 

overdose deaths (Centers for Disease Control 

and Prevention, 2011). 

Opioid use and related consequences also vary 

by several key demographics. For example, 

the Medicaid patient population is more 

likely to receive prescriptions for opioid pain 

medications and to have opioids prescribed 

at higher doses and for longer periods of time 

than the non-Medicaid patient population. 

Opioid medication overdose deaths are also 

more common among Medicaid-eligible 

populations (BHCC, 2013).

The overall rate of first time heroin use 

increased among all women, from 0.06 percent 

in 2002–2004 to 0.10 percent in 2009–2011, 

estimated to be an increase from 43,000 

women to 77,000 women (SAMHSA, 2013). 

Among women, the number of overdose 

deaths due to the use of prescription opioid 

pain medications has increased significantly 

since 2007, surpassing deaths from motor 

vehicle-related injuries. Overdose deaths due 

to opioid medication increased among women 

more than 5-fold between 1999 and 2010, 

totaling 47,935 during that period (CDC, 2013). 

From 1992 to 2012, treatment admissions for 

pregnant women among all female admissions 

remained stable at four percent. However, 

the proportion of pregnant women entering 

treatment who reported any prescription 

opioid misuse increased substantially from 

two percent in 1992 to 28 percent in 2012, 

an increase from 351 to 6,087 women. The 

proportion of pregnant women who entered 

treatment and reported prescription opioids 

as their primary substance increased from 

one percent in 1992 to 19 percent in 2012, an 

increase from 124 to 4,268 women (Martin, 

Longinaker, & Terplan, 2014). 

Neonatal Abstinence 

Syndrome 

Among infants, the incidence of NAS increased 

from 1.20 per 1,000 hospital births in 2000 to 

3.39 in 2009 (Patrick et al., 2012) and 5.80 in 

2012 (Patrick, Davis, Lehmann & Cooper, 2015). 

In a study of 299 neonatal intensive care units 

(NICU) across the country, the rate of NICU 

admissions for infants with NAS increased 

from 7 cases per 1,000 admissions in 2004 to 

27 cases per 1,000 admissions in 2013 (Tolia, 

Patrick, Bennett, Murthy, Sousa, Smith, Clark & 

Spitzer, 2015). The study by Patrick et al. (2012) 

did not distinguish between NAS that resulted 

from illicit opioids, prescription opioid pain 

medications, or MAT. Between 2006 and 2012, 

the rate of infant and maternal hospitalizations 

related to substance use increased substantially, 

from 5.1 to 8.7 per 1,000 infant hospitalizations 

and from 13.4 to 17.9 per 1,000 maternal 

hospitalizations, resulting in a total cost of $944 

million in 2012 (Fingar, Stocks, Weiss & Owens, 

2015). In 2012, among the neonatal stays with 

a substance-related condition, approximately 

60% were related to neonatal drug withdrawal 

or NAS. Among maternal stays related to 

substance abuse, almost one-fourth involved 

opioids (Finger et al., 2015).

As previously discussed, NAS is the term 

used to represent the pattern of effects that 

are associated with opioid withdrawal in 

newborns (Hudak & Tan, 2012). NAS symptoms 

are affected by a variety of factors, including 

the type of opioid the infant was exposed to, 

the point in gestation when the mother used 

the opioid, genetic factors, and exposure 

to multiple substances (Wachman, Hayes, 

Brown, Paul, Harvey-Wilkes, Terrin, Huggins, 

Aranda, & Davis, 2013). To assess the severity 

of the infant’s symptoms, a scoring system, 
7

such as the Finnegan Neonatal Abstinence 

Scoring System or the Lipsitz Neonatal DrugWithdrawal Scoring System is used. The results 

of the scoring system are used in conjunction 

with an assessment of other factors, including 

the infant’s gestational age, overall health, 

medical history, exposure to other substances, 

and tolerance or response to medications, to 

determine the course of treatment (Jansson, 

Velez, & Harrow, 2009). 

Non-pharmacological treatment is the standard 

of care for the infant with NAS and should start 

at birth and continue throughout the infant’s 

hospitalization and beyond (Velez & Jansson, 

2008). Non-pharmacological treatment seeks 

to soothe the infant’s symptoms, while also 

encouraging the mother–infant bond. Some 

of the symptoms associated with NAS can be 

challenging and disruptive to the attachment 

between the mother and infant, particularly 

for women who have substance use disorders 

and may have difficulty responding to an 

infants’ cues. Non-pharmacological methods 

include rooming together post-delivery 

and modification of the environment to 

support attachment and provide a soothing 

environment for the infant. Environmental 

modifications include swaddling the infant 

and reducing his or her exposure to light and 

excessive noise.

Pharmacological treatment is primarily intended 

to relieve NAS symptoms and its associated 

complications, such as fever, weight loss, and 

seizures. Pharmacological treatment typically 

entails using a neonatal morphine solution 

or methadone (Hudak & Tan, 2012). Supports 

are necessary to address the challenges and 

risk factors that mothers and infants may face 

following discharge from the hospital. As 

previously described, women with opioid use 

disorders often face complex psychosocial, 

environmental, and cultural factors that can 

impact treatment, recovery, and parenting. 

Post-discharge supportive services can include 

identifying family or others for social support 

Treatment considerations 

for newborns with prenatal 

substance exposure are 

available in a 2012 clinical 

report from the American 

Academy of Pediatrics. The 

Academy recommends that 

staff with training in identifying 

signs of withdrawal monitor 

these infants and initiate 

therapy when indicated.

“Each nursery that cares 

for infants with neonatal 

withdrawal should develop a 

protocol that defines indications 

and procedures for screening 

for maternal substance abuse. 

In addition, each nursery 

should develop and adhere 

to a standardized plan for the 

evaluation and comprehensive 

treatment of infants at risk for or 

showing signs of withdrawal.” 

 —Hudak & Tan, 2012

and participating in ongoing support groups, 

counseling, housing services, and follow-up 

services for the infant. See Appendix 5: Children 

and Recovery Mothers (CHARM) Collaborative in 

Burlington, Vermont: A Case Study, for information 

on post-discharge supportive services.

The advent of new medications used in treating 

opioid use disorders during pregnancy calls 

for additional studies on the long-term impact 

of prenatal exposure to opioids to better 

understand the best course of treatment for 

affected children (Wahlsten & Sarman, 2013; 

Hamilton, McGlone, MacKinnon, Russell, 

Bradnam, & Mactier, 2010; Farid, Dunlop, Tait, & 

Hulse, 2008).
8

Guidelines for 

Supporting 

Collaborative Policy 

and Practice 

This guidance is intended to support the 

development of collaborative, interagency 

policies and practices that can assist 

communities to develop approaches that 

support the health, safety, well-being, and 

recovery of pregnant women with opioid use 

disorders and their infants. These approaches 

begin with prevention strategies designed to 

help all women of childbearing age, as well as 

their health care providers, to understand both 

the implications of opioid use during pregnancy 

and the interventions in the prenatal period 

that extend through—and ideally beyond—the 

postpartum time frame. This guidance highlights 

key decision points and recommended strategies 

based on the research literature as well as 

evidence from innovative strategies being 

implemented around the country. 

Any response to the many barriers facing the 

families of pregnant women with opioid use 

disorders must be grounded in solutions within 

the community that reflect best practices 

(e.g., evidence-based practices) as well as 

perspectives, resources, and policies that address 

the needs of the community. A number of 

communities across the United States have 

developed collaborative initiatives to make 

systems and processes work more effectively 

for women with opioid use disorders and their 

infants. Although these approaches vary, they 

share a focus on coordinating the goals and 

efforts of an array of partners. In particular, 

efforts focus on effective screening and linkages 

to treatment in the prenatal period, as well as 

efficient communication between hospitals 

and community partners. One of these welldeveloped initiatives is described in the case 

study in Appendix 5: Children and Recovery 

Mothers (CHARM) Collaborative in Burlington, 

Vermont: A Case Study.

Existing Guidelines

Research shows that a combination of 

medication and behavioral therapies is the most 

successful way to treat opioid use disorders and 

increases the likelihood of cessation of opioid 

abuse (CSAT, 2005). Similarly, the literature 

summarizing the most current research offers 

best-practice guidance for developing efficacious 

practices and policies for women with opioid use 

disorders and their infants. 

Recommendations have been published in the 

last several years by national and international 

organizations, such as the American College of 

Obstetricians and Gynecologists (ACOG), World 

Health Organization (WHO), US HHS, SAMHSA, 

American Society of Addiction Medicine (ASAM), 

Legal Action Center, and American Academy 

of Pediatrics. Although this publication is not 

intended to provide an exhaustive literature 

review, some of the key recommendations from 

these organizations are cited throughout, and 

select highlights are presented in the section that 

follows. Links to these publications are provided 

in Appendix 3: Training Needs and Resources .

American College of Obstetricians and 

Gynecologists and American Society of 

Addiction Medicine

The following excerpt from the 2012 ACOG and 

ASAM Committee Opinion on Opioid Abuse, 

Dependence, and Addiction in Pregnancy 

summarizes the current knowledge of the risks 

and benefits of MAT for opioid use during the 

prenatal and postpartum period.
9

Opioid use in pregnancy is not uncommon, and the 

use of illicit opioids during pregnancy is associated 

with an increased risk of adverse outcomes. The 

current standard of care for pregnant women with 

opioid use disorders is referral for opioid-assisted 

therapy with methadone, but...evidence suggests 

that buprenorphine also should be considered. 

Medically supervised tapered doses of opioids 

during pregnancy often result in relapse to former 

use.7 Abrupt discontinuation of opioids in an 

opioid-dependent pregnant woman can result in 

preterm labor, fetal distress, or fetal demise. During 

the intrapartum and postpartum period, special 

considerations are needed for women who are opioid 

dependent to ensure appropriate pain management, 

to prevent postpartum relapse and a risk of overdose, 

and to ensure adequate contraception to prevent 

unintended pregnancies. Patient stabilization 

with opioid-assisted therapy is compatible with 

breastfeeding. Neonatal abstinence syndrome is an 

expected and treatable condition that follows prenatal 

exposure to opioid agonists. All infants born to 

women who use opioids during pregnancy should be 

monitored for neonatal abstinence syndrome and be 

treated if indicated.

The WHO’s Guidelines for the identification and 

management of substance use and substance use 

disorders in pregnancy (2014) provide technical 

guidance primarily for health care professionals 

who work with women and their infants from 

conception to birth as well as during the 

postnatal period. The publication also offers 

guidelines on identifying and managing alcohol 

and other substance use in pregnant women, 

with the goal of ensuring healthy outcomes 

for both pregnant women and their infants. 

While developing the recommendations, 

WHO established the following overarching 

principles to provide guidance in planning, 

implementing, and evaluating the most relevant 

recommendations, based on regional contexts 

and available resources.

7

 The optimal methadone dosage for pregnant women generally increases throughout pregnancy, and this increase does 

not necessarily increase fetal exposure to methadone. See John Drozdick, III, et al., Methadone Trough Levels in Pregnancy, 187 

American Journal of Obstetrics and Gynecology, 1184 (2002); John J. McCarthy, Addiction Treatment Forum, Methadone Dosing 

During Pregnancy: Does Anyone Have a Clue? (Oct. 2012).

World Health Organization

PRIORITIZING PREVENTION. Preventing, 

reducing and ceasing the use of alcohol, tobacco 

and illicit drugs before and during pregnancy 

and in the postpartum period for breastfeeding 

mothers are essential for optimizing the health 

and well-being of women and their children. 

Ensure that women who are receiving opioid 

treatment for a medical condition understand 

the risks of prenatal exposure and have access to 

highly effective birth control methods.

ENSURING ACCESS TO PREVENTION AND 

TREATMENT SERVICES. All pregnant women 

and their families affected by substance use 

disorders should have access to affordable 

prevention and treatment services and 

interventions delivered with special attention to 

confidentiality, legal and human rights; women 

should not be excluded from accessing health 

care because of their substance use. Treatment, 

especially residential programs, for postpartum 

women should incorporate consideration for the 

infant and siblings.

RESPECTING PATIENT AUTONOMY. The 

autonomy of pregnant and breastfeeding women 

should always be respected; each woman with a 

substance use disorder needs to be fully informed 
10

about the risks and benefits, for herself and for 

her fetus or infant, of available treatment options, 

when making decisions about her health care and 

the care of her infant.

PROVIDING COMPREHENSIVE CARE. Services 

for pregnant and breastfeeding women with 

substance use disorders should have a level of 

comprehensiveness that matches the complexity 

and multifaceted nature of substance use 

disorders and their antecedents in this population.

SAFEGUARDING AGAINST DISCRIMINATION 

AND STIGMATIZATION. Interventions should be 

provided to pregnant and breastfeeding women in 

ways that prevent stigmatization, discrimination, 

criminalization, and marginalization of women 

seeking treatment to benefit themselves and their 

infants. Prevention and treatment should promote 

and facilitate family, community and social support 

as well as social inclusion by fostering strong 

links with available childcare, economic supports, 

education, housing, and relevant services.

In addition to these principles, WHO makes 

specific practice recommendations. One 

recommendation suggests that pregnant 

women should be advised to continue or begin 

opioid maintenance therapy with methadone or 

buprenorphine. 

American Society of Addiction Medicine

ASAM’s National Practice Guideline for the Use 

of Medications in the Treatment of Addiction 

Involving Opioid Use (2015) provides information 

on evidence-based treatment of opioid use 

disorder, including guidelines for the treatment 

of pregnant women. The publication discusses 

recommendations on assessment and diagnosis, 

treatment, and the use of psychosocial treatment 

in conjunction with medications. ASAM’s 

recommendations for the treatment of opioid use 

disorders in pregnant women include: 

ASSESSMENT OF OPIOID USE DISORDER 

IN PREGNANT WOMEN. A comprehensive 

assessment, including medical examination 

and psychosocial assessment is recommended 

in evaluating opioid use disorder in pregnant 

women. The clinician should ask questions in 

a direct and nonjudgmental manner to elicit a 

detailed and accurate history. 

OPIOID AGONIST TREATMENT IN PREGNANCY. 

Decisions to use opioid agonist medications 

in pregnant women with opioid use disorder 

revolve around balancing the risks and benefits 

to maternal and infant health. Opioid agonist 

treatment is thought to have minimal long-term 

impacts on children relative to harms resulting 

from maternal use of heroin and prescription 

opioids. Therefore, women with opioid use 

disorder who are not in treatment should be 

encouraged to start opioid agonist treatment 

with methadone or buprenorphine monotherapy 

(without naloxone) as early in the pregnancy as 

possible. Pregnancy in women with opioid use 

disorder should be co-managed by an obstetrician 

and an addiction specialist physician.

OPIOID AGONISTS VERSUS WITHDRAWAL 

MANAGEMENT. Pregnant women who are 

physically dependent on opioids should receive 

treatment using agonist medications rather 

than withdrawal management or abstinence 

as these approaches may pose a risk to the 

fetus. Furthermore, withdrawal management 

has been found to be inferior in effectiveness 

over pharmacotherapy with opioid agonists 

and increases the risk of relapse without fetal or 

maternal benefit.
11

INDUCTION AND DOSING OF OPIOID 

AGONISTS. Treatment with methadone should 

be initiated as early as possible during pregnancy. 

BREASTFEEDING. Mothers receiving methadone 

and buprenorphine monoproduct for the 

treatment of opioid use disorders should be 

encouraged to breastfeed.

In addition to these aforementioned 

organizations, state and local jurisdictions 

have developed guidelines for hospitals, 

child welfare agencies, treatment providers, 

and other care providers regarding MAT, NAS 

treatment, and responses to pregnant women 

with opioid dependency. These guidelines 

may help ensure a more consistent approach 

among communities within a given state or 

region. Addressing disparities in treatment 

related to resource shortages and geographic 

and financial barriers to accessing health care 

and other services is another vital consideration 

in meeting the needs of pregnant women with 

opioid use disorders. 

One example of a regional approach that 

incorporates best practice guidelines is the 

CHARM Collaborative in Burlington, Vermont— 

a multidisciplinary group of agencies serving 

women with opioid use disorders and their 

families during pregnancy and through 

infancy. The CHARM Collaborative focuses on 

meeting the needs of pregnant and postpartum 

women who have a history of opioid use and 

their infants. This group emerged in the late 

1990s in response to the increasing need 

for MAT resources for pregnant women with 

opioid use disorders. Today, the CHARM 

Collaborative includes 11 organizations that 

collectively provide this population of women 

with coordinated comprehensive care from 

child welfare, medical (including obstetrics and 

pediatrics) and substance abuse treatment 

professionals across Vermont. Their efforts 

have ensured that the vast majority of pregnant 

women are identified and provided treatment 

during the prenatal period. They jointly develop 

plans for the infant and family’s safety and 

well-being prior to the baby’s birth. Additional 

information on the approach and practices of 

the CHARM Collaborative is provided in Appendix 

5: Children and Recovery Mothers (CHARM) 

Collaborative in Burlington, Vermont: A Case Study.

Need for Collaboration 

Among Multiple Agencies

Professionals in the child welfare, judicial, 

medical (including obstetrics, pediatrics, 

substance abuse treatment, and mental health), 

and addiction treatment systems generally share 

significant concerns about pregnant women 

who misuse opioids and newborns with NAS 

and other problems related to in utero drug or 

alcohol exposure. However, this is often where 

the consensus ends. At times, the responses of 

various systems to the needs of these families 

diverge, resulting in apparent conflicts among 

treatment practices, medical recommendations, 

and the policies and oversight provided by courts 

and child welfare services.

The types of agencies and professionals that 

provide treatment and other services to 

pregnant women with opioid use disorders 

and their infants can vary widely from one 

community to another. A considerable range 

and mix of approaches, settings, programs, 

and professionals can be involved, and health 

and social service systems typically operate 

and intersect in ways that are unique to each 

community. This mixture of participating 

systems and relationships among them 

affects service coordination. For example, 

several different professionals and specialty 

providers within the medical care system (i.e., 

an obstetrician, neonatologist, pediatrician, 

and addiction specialist) might provide care 

to a woman and her infant during the prenatal 

and postpartum periods. Within the substance 

abuse treatment system, treatment is delivered 

in a variety of settings (e.g., residential facilities, 

outpatient clinics, and offices of physicians 

who provide MAT), using a combination of 

therapeutic approaches (e.g., medications, 

individual and group counseling, and self-help 

groups). In the child welfare system, services 

are delivered along a continuum, based on risk 
12

and safety factors that range from supports to 

children remaining in the custody of their parents 

(often referred to as in-home services) to out-ofhome care (e.g., foster or kinship care).

Different systems and provider communities 

also have different policies, priorities, and 

perspectives. For example, hospitals—even 

those in the same state or county—often have 

inconsistent protocols for screening infants for 

prenatal substance exposure and sometimes 

have seemingly inconsistent practices for 

contacting child welfare agencies if substance 

use is detected or NAS is diagnosed. Even 

when hospitals have clear policies in place, 

adherence to these policies depends largely 

on the relationships between hospital staff and 

child welfare workers. Adherence to policies also 

varies by medical team members’ perceptions 

“Medication-Assisted Treatment 

(MAT) is an evidence-based practice 

that combines pharmacological 

interventions with substance abuse 

counseling and social support. 

Although not for everyone, it is an 

essential part of the comprehensive 

array of services available to people 

struggling with addiction to alcohol 

or other drugs. 

A paradox in our field is that 

although we recognize addiction as 

a chronic, relapsing disease, some 

substance abuse counselors and 

administrators have been reluctant 

to embrace new technologies for 

its treatment. At the same time, 

most physicians and other health 

care professionals receive little 

or no training in the treatment of 

addiction. As a result, adoption of 

MAT has been slow in some areas.”

— Mark G. Stringer, Director

Missouri Department of Health, 

Division of Behavioral Health

of whether a positive toxicology screen for the 

newborn is likely to trigger legal consequences 

for the mother, which may be perceived to 

not be in the best interest of the mother and 

infant (National Abandoned Infants Assistance 

Resource Center, 2012).

The fact that many non-medical professionals 

can potentially affect treatment decisions for 

pregnant women with opioid use disorders 

further exacerbates the care of women and 

their infants. These professionals may include 

judges (if the woman is involved in the criminal 

justice system) or residential substance abuse 

treatment providers that do not offer MAT. If a 

woman is already involved in the child welfare 

system as a result of a case related to her older 

children, child welfare social workers and 

judicial representatives related to this separate 

case also influence decisions regarding her care, 

and these decisions might not be consistent 

with her treatment plan or best practice 

recommendations. If a woman is receiving 

MAT in an opioid treatment program (OTP) or 

buprenorphine from her doctor, she is likely to 

experience conflict if she also participates in a 

substance abuse treatment program or a mutual 

aid support group that does not embrace the 

use of MAT. It is essential to recognize that each 

mutual aid support group is autonomous and 

self-directed; and group members may have 

their own views on the use of MAT. Despite this 

potential conflict, each professional and the 

organizations or systems that they represent are 

responding to the directives issued from their 

respective fields of practice. If no such directives 

exist, they must rely on their best professional 

judgment when making critical decisions that 

affect women and their infants and that have 

the potential to impact entire families. 

Every professional involved needs to 

understand the different contexts of opioid 

use by a pregnant woman to accurately assess 

her distinct needs and those of her family 

members in order to implement the most 

appropriate and comprehensive plan of care. 

In addition to being familiar with effective and 

evidence-based addiction treatment, treatment 

counselors, social workers, health care 
13

providers, and legal system professionals need 

to be aware of the primary risk and protective 

factors that promote or inhibit resiliency in 

women and their children. These factors have 

a direct impact on the types and intensities of 

support and supervision that a woman requires 

throughout pregnancy as well as during the 

critical first year of parenting a newborn. 

For example, child welfare agencies have the 

complicated dual role of supporting families 

while monitoring them to prevent child 

maltreatment. These agencies have risk and 

safety assessment policies and practices that are 

intended to identify immediate safety concerns 

for children, while evaluating the risk and 

protective factors of each family. When making 

decisions about whether to intervene and how 

to do so in the most supportive manner, staff 

must take into account the distinctions related 

to a woman’s history, motivation, and pattern of 

opioid use (and other drug use).

The Child Abuse and Prevention Treatment Act 

(CAPTA) Reauthorization Act of 2010 require 

states to have policies and procedures for 

hospitals to notify child protective services 

(CPS) of all children born who are affected by 

illegal substance use or withdrawal symptoms 

resulting from prenatal drug exposure or 

The privacy provisions in the U.S. 

Code of Federal Regulations (C.F.R.), 

Title 42, Part 2, describe the limited 

circumstances in which information 

about a patient’s treatment for a 

substance use disorder may be disclosed 

with and without the patient’s consent. 

The regulations are available at http://

www.ecfr.gov/cgi-bin/text-idx?c=ecfr&si

d=b7e8d29be4a2b815c404988e29c06a3

e&rgn=div5&view=text&node=42:1.0.1.

1.2&idno=42

42 C.F.R. 2 applies to all clinicians 

who use a controlled substance (i.e., 

methadone and buprenorphine) 

for detoxification or maintenance 

treatment of a substance use disorder. 

Such physicians must register with 

the federal Drug Enforcement Agency 

(DEA), and their DEA license, along with 

representations concerning their status 

as opioid treatment providers, makes 

them subject to the regulations.

With limited exceptions, 42 C.F.R. 2 

requires patient consent for disclosures 

of protected health information, even 

for the purposes of treatment, payment, 

or health care operations. Consent for 

disclosure must be in writing.

42 C.F.R. 2 does not apply to information 

on substance use treatment maintained 

in connection with the Veterans’ 

Administration or the Armed Forces 

(42 CFR § 2.12 (c)).

Most substance-abuse treatment 

programs are also subject to the 

Health Insurance Portability and 

Accountability Act of 1996 Privacy 

Rule. In 2004, SAMHSA issued a 

guidance document that summarizes 

the differences between the two rules 

and implementation solutions, which 

is available at http://www.samhsa.

gov/sites/default/files/part2-hipaacomparison2004.pdf

Frequently asked questions (FAQs) 

about substance abuse confidentiality 

regulations are available on the SAMHSA 

website. The FAQs include information 

on exceptions to 42 C.F.R. 2 (e.g. medical 

emergencies) and guidance on which 

entities or individuals are subject to 

the regulations. http://www.samhsa.

gov/about-us/who-we-are/laws/

confidentiality-regulations-faqs
14

indications of FASD (CAPTA, 2010). CAPTA 

requires CPS agencies to develop a plan of 

safe care for every such infant referred to their 

agency and address the health and substance 

use disorder treatment needs of the infant. The 

2016 Title V, Section 503, “Infant Plan of Safe 

Care” of S. 524, “Comprehensive Addiction and 

Recovery Act of 2016” requires the plan of safe 

care to also address the treatment needs of 

affected family or caregivers and requires states 

to develop a monitoring system to determine 

whether and how the local entities are providing 

referrals to and delivery of appropriate services 

for the infant and affected family or caregiver. 

The Comprehensive Addiction and Recovery Act 

of 2016 was signed into law on July 22, 2016. 

CAPTA also requires that all children who are 

younger than three years who are substantiated 

victims of child maltreatment are referred 

to early intervention agencies that provide 

developmental disabilities services (Office on 

Child Abuse and Neglect, 2003). However, state, 

tribal, and local agency policies determine how 

newborns with prenatal substance exposure are 

identified, whether notice to CPS constitutes 

a report alleging child abuse or neglect, and 

the level and type of proof needed to warrant 

further investigation (Young et al., 2009 ). For 

these reasons, CPS agencies handle referrals 

of infants with prenatal substance exposure in 

ways that vary greatly by state and community. 

A February 2015 analysis by the Guttmacher 

Institute showed that four states require 

health care professionals to test newborns 

for prenatal drug exposure when drug use is 

suspected, while 15 states require providers to 

report women to CPS for suspected drug use 

during pregnancy (Guttmacher Institute, 2015). 

Different CPS agencies also make very different 

decisions regarding whether an infant remains 

in the custody of the mother. These decisions 

determine how infants are evaluated for early 

intervention service needs and whether they 

receive these services when needed. These 

inconsistencies in policy and practice result in 

differing approaches across communities to 

identify pregnant women in need of treatment 

and different responses for the infant’s care and 

safety considerations.

In addition to these practice and policy concerns, 

there are often knowledge gaps about the risk 

and safety of a newborn who tests positive 

for opioids. For example, professionals need 

to understand distinctions in risk and safety 

between infants exposed to opioids as a result 

of the mother’s opioid use or misuse versus 

infants exposed to opioids as a result of the 

mother’s treatment for opioid dependency with 

medications under a doctor’s care. In addition, in 

the well-meaning effort to maintain child safety, 

child welfare agencies may establish uninformed 

requirements on minimal dosing of MAT 

medications or withdrawal from MAT for women 

as a condition for keeping custody of their 

newborns8

 and may use a positive toxicology 

result for methadone or buprenorphine at birth 

as a presumptive cause for child removal.

These decisions often have negative and 

sometimes irrevocable consequences for 

families, including interference with the 

critical mother–infant attachment process. In 

addition, many Family Treatment Drug Courts 

(FTDCs) around the country treat a woman’s 

use of MAT as a criterion for excluding her from 

participating in or graduating from the program 

until she is no longer taking medications. The 

National Association of Drug Court Professionals 

(NADCP) resolved that drug courts should 

not impose blanket prohibitions against the 

use of MAT for their participants and further 

suggests that drug courts attain reliable expert 

consultation on the appropriate use of MAT for 

their participants, including partnering with 

substance abuse treatment programs (NADCP, 

2013). In addition, recognizing that MAT may be 

an essential part of a comprehensive treatment 

plan, SAMHSA Treatment Drug Court grantees 

were encouraged, beginning in 2015, to use a 

percentage of the annual grant award to pay for 

FDA-approved medications.

State laws vary regarding legislation on the use 

of substances during pregnancy. The variance 

includes whether there is criminal prosecution 

or if substance use is considered maltreatment 

and grounds for termination of parental rights 

under civil statutes. The 2013 National Drug 

Control Strategy states that criminal justice 

professionals should include the use of MAT 

8

 Minimal dosing may in fact increase the likelihood of relapse as well as increase risks to both the mother and infant. Important 

health issues are associated with proper dosing. (Kaltenbach et al., 1998)
15

as appropriate treatment for an opioid use 

disorder for those individuals involved in 

the judicial system (Office of National Drug 

Control Policy, 2013). The previously described 

analysis by the Guttmacher Institute showed 

that one state allows assault charges to be 

filed against pregnant women who use certain 

substances and that 18 states consider evidence 

of substance use during pregnancy (often 

only evidence of use and not a diagnosis of 

dependency or addiction or findings of harm) 

to indicate child abuse and provide grounds 

for termination of parental rights (Guttmacher 

Institute, 2015). On the other hand, some 

states have begun to implement Safe Harbor 

legislation to facilitate access to treatment for 

pregnant women. Safe Harbor laws provide a 

provision in a law or agreement that protects 

against liability or penalty as long as set 

conditions have been met. Two states have 

implemented or introduced Safe Harbor laws in 

which pregnant women who seek treatment for 

opioid and other substance use disorders, in the 

absence of other risk or safety factors, will not 

have to fear risking loss of custody of their infant 

or termination of parental rights. 

8

 Minimal dosing may in fact increase the likelihood of relapse as well as increase risks to both the mother and infant. Important 

health issues are associated with proper dosing. (Kaltenbach et al., 1998)

As amended in 2010, the Child Abuse 

Prevention and Treatment Act (CAPTA) 

requires states to include the following in 

their state plans. 

An assurance in the form of a certification 

by the Governor of the State that the 

State has in effect and is enforcing a State 

law, or has in effect and is operating a 

statewide program relating to child abuse 

and neglect that includes:

A) policies and procedures (including 

appropriate referrals to child protection 

service systems and for other appropriate 

services) to address the needs of infants 

born with and identified as being affected 

by illegal substance abuse or withdrawal 

symptoms resulting from prenatal drug 

exposure, or a Fetal Alcohol Spectrum 

Disorder, including a requirement that 

health care providers involved in the 

delivery or care of such infants notify 

the child protective services system of 

the occurrence of such condition in such 

infants, except that such notification 

shall not be construed to: (I) establish 

a definition under Federal law of what 

constitutes child abuse or neglect; or (II) 

require prosecution for any illegal action; 

B) the development of a plan of safe care 

for the infant born and identified as being 

affected by illegal substance abuse or 

withdrawal symptoms, or a Fetal Alcohol 

Spectrum Disorder.

The CAPTA Reauthorization Act of 2010 

is available at: http://www.gpo.gov/

fdsys/pkg/BILLS-111s3817enr/pdf/BILLS111s3817enr.pdf

— Section 106(b)(2)(B)(ii-iii) of the Child 

Abuse Prevention and Treatment Act 

[42 U.S.C. 5106a(b)(2)(B)(ii-iii)]

Title V, Section 503, “Infant Plan of 

Safe Care,” of S. 524, “Comprehensive 

Addiction and Recovery Act of 2016” was 

signed into law on July 22, 2016. The 

bill amends CAPTA to address the health 

and substance use disorder treatment 

needs of the infant and affected family or 

caregiver; and to ensure the development 

and implementation by the State of 

monitoring systems regarding the 

implementation of plans to determine 

whether and in what manner local entities 

are providing, in accordance with State 

requirements, referrals to and delivery of 

appropriate services for the infant and 

affected family or caregiver.

The 2016 changes also provide monitoring 

and oversight changes for HHS.

The Comprehensive Addiction and 

Recovery Act of 2016 is available at: 

https://www.congress.gov/bill/114thcongress/senate-bill/524
16

The various configurations and approaches in 

each discipline can exacerbate the challenges 

in coordinating services among providers, 

agencies, and organizations. The many 

differences that exist need to be reconciled 

to facilitate a coordinated cross-disciplinary 

approach. The purpose of this document is to 

assist communities in assessing their current 

practice and to develop practice and policy 

improvements to better meet the needs of 

these families.

Comprehensive 

Framework for 

Intervention

As discussed in the previous section, many 

professionals may be involved in decisions 

related to the treatment, care, and supervision 

of pregnant women with opioid use disorders. 

These decision makers might include health 

care providers, substance abuse treatment 

providers, child welfare workers, and judicial 

system representatives (e.g., judges, parents’ 

lawyers, and children’s lawyers or advocates). 

Each of these professionals and the systems they 

represent are responding to directives that stem 

from a combination of federal regulations, state 

legislation, ethics, and system-specific guidelines.

Ideally, these directives are aligned to ensure 

the best possible outcomes for both mothers 

and infants. Unfortunately, however, this is not 

usually the case, particularly when state laws 

or agency policies are silent on or conflict with 

best practices, or are driven by misinformation. 

When directives are unclear, conflicting, or 

missing, workers must rely on their professional 

judgment to determine the best approach and 

course of action.

Without proper training and knowledge 

about best practices, professionals might 

not serve the best interests of mothers, 

children, and families. To surmount this risk, 

professionals must establish mechanisms for 

working together across systems, agencies, 

and providers to develop a coordinated and 

cohesive approach. Such an approach has 

the highest likelihood of achieving successful 

outcomes related to maternal and child health, 

newborn care, mother–infant attachment, 

positive parenting practices, child safety, and 

family well-being. 

Strategies to help are typically most effective 

when designed to address needs beyond 

substance abuse treatment, such as for cooccurring mental health issues, trauma, 

housing, child care, employment, parenting, 

and a range of other personal supports. A 

family-centered and gender-responsive 

approach addresses many of these needs in a 

culturally responsive9

 manner (Werner, Young, 

Dennis, & Amatetti, 2007; King, Duan, & Amaro, 

2014). When states, tribes, and communities 

recognize the positive and often cost-effective 

impact of a collaborative approach, public 

agencies and private providers have a powerful 

incentive to work together in alternative and 

innovative ways.

Overview of SubstanceExposed Infants (SEI) 

Framework

This guidance leverages and is informed by the 

five-point intervention framework developed 

by the NCSACW and funded by SAMHSA 

and the Administration on Children, Youth, 

and Families. This framework, which was the 

organizing foundation for the SAMHSA report 

Substance-Exposed Infants: State Responses 

to the Problem, serves as a comprehensive 

model that identifies five major time frames 

when intervention in the life of an infant can 

help reduce the potential harm of prenatal 

substance exposure (Young et al., 2009). 

9

 For more information on cultural competence, see SAMHSA’s Treatment Improvement Protocol (TIP) 59 – Improving Cultural 

Competence (http://store.samhsa.gov/shin/content//SMA14-4849/SMA14-4849.pdf).
17

The five points of intervention are:

1. Pre-pregnancy: During this time, 

interventions can include promoting 

awareness among women of child-bearing 

age and their family members of the 

effects that prenatal substance use can 

have on infants.

2. Prenatal: During this time, health care 

providers have the opportunity to screen 

pregnant women for substance use as 

part of routine prenatal care and to make 

referrals that facilitate access to treatment 

and related services for the women who 

need these services. 

3. Birth: Interventions during this time 

include health care providers testing 

newborns for prenatal substance exposure 

at the time of delivery.

4. Neonatal: During this time, health care 

providers can conduct a developmental 

assessment of the newborn and ensure 

access to services for the newborn as well 

as the family.

5. Throughout childhood and adolescence: 

During this time, interventions include the 

ongoing provision of coordinated services 

for both child and family.

The framework also illustrates the following 

key issues:

The NCSACW’s five-point framework emerged 

from a multi-year review and analysis of 

existing policies and practices in 10 states 

regarding prenatal exposure to alcohol and 

other drugs. This effort was designed to help 

state, tribal, and local governments to identify 

opportunities for strengthening interagency 

efforts that address prevention, intervention, 

identification, and treatment of complications 

related to prenatal substance exposure. The 

framework focuses on immediate and ongoing 

services for infants, mothers, and families. The 

NCSACW reviewed states’ policies regarding:

§ The birth event is only one of several 

opportunities to affect outcomes. Therefore, 

it is important to understand the extent of 

those opportunities and which interventions 

are most needed and most likely to be 

effective at each point in time.

§ Cross-system linkages are necessary to ensure 

services are coordinated across the spectrum 

of prevention, intervention, and treatment.

ACOG’s 2015 legislative priorities 

include promoting public health 

efforts to reduce maternal opioid 

dependence and NAS as well as 

opposing punitive legislation 

against women with opioid 

dependence whose babies are born 

with NAS (ACOG, 2015). 

§ Pre‐pregnancy efforts to engage women 

with substance use disorders in treatment to 

prevent prenatal substance exposure in the 

women’s future infants.

§ Screening and assessment during pregnancy 

to ensure that women have access to 

treatment and needed supports.

§ Health care, supportive services at birth, and 

notification of CPS when infants are identified 

as having been prenatally affected by illegal 

substances, as consistent with CAPTA.

§ Services to infants with prenatal substance 

exposure or infants who require care (along 

with their parents and siblings) during the 

neonatal period.

§ Ongoing coordinated services for this 

population of children and their families 

throughout childhood and adolescence 

(Young et al., 2009).

This review showed a wide variation in state 

policies and practices related to meeting 

the needs of infants with prenatal substance 

exposure, thus highlighting the need for 

guidance based on best practices and current 

literature in the field. This guidance also 

needs to provide recommendations that 

can be adapted and customized to benefit 

women and children within the context of 

each community’s unique mix of resources, 

challenges, and perspectives.
18

Compared to efforts by individual 

agencies and systems, collaboration 

across multiple agencies and systems, 

coupled with strong leadership and 

consistent communication, offers 

a more effective approach, a more 

efficient way of doing business, and 

ultimately leads to better outcomes.

This five-point intervention framework 

highlights opportunities for cross-system 

collaboration and policy development at each 

critical point in time, from pre-pregnancy 

throughout an infant’s early years. The 

framework also integrates recommendations 

for best practices related to outreach, 

engagement, treatment, and support for 

mothers and their infants along the five-point 

continuum. The framework shows that no 

single system has the necessary resources, 

information, or influence needed to adequately 

serve this vulnerable mother–infant dyad 

and other involved family members who 

are likely to need services. All those who 

have a role in improving outcomes for such 

families need to collaborate in order to put the 

necessary policies and practices in place. These 

collaborations can set the stage for maternal 

recovery from substance use disorders, child 

safety, and the well-being of all those involved.

A Guide for 

Collaborative Planning

The opportunity for practice and policy 

improvement exists largely because so many 

different agencies, organizations, and providers 

have a legal or professional responsibility to 

act or address the needs of pregnant women 

with opioid use disorders and their infants. 

Without a comprehensive coordinated response 

that includes child welfare and healthcare, 

including obstetrics, pediatrics, substance abuse 

treatment, and mental health professionals, 

families are not well served. Cross-system 

initiatives lead to better results by facilitating 

better communication, clearly defining the 

roles of the various professionals who serve 

these families, and maximizing the resources 

of multiple stakeholders who have a vested 

interest in accomplishing shared goals.

Efforts that specify the roles and 

responsibilities of each partner help ensure 

that efforts from multiple systems to support 

individuals, families, and communities have a 

stronger cumulative impact and are sustained 

over time to address the full range of practice 

and policy considerations (Young, Nakashian, 

Yeh, & Amatetti, 2006). However, collaborative 

practice can be difficult to establish and 

implement for a number of reasons, including 

competing priorities, rules in agencies or 

organizations that conflict with the approaches 

of others, lack of leadership, confusion about 

roles, unmet training needs, use of different 

terminologies, limits on time and resources, 

information gaps, and mistrust. Communities 

are often unprepared to provide services to 

the large number of pregnant women who 

misuse prescription medications and heroin, 

and these agencies have not yet organized a 

coordinated response. In other communities, 

all of the involved parties might not know the 

rules, regulations, and practice standards that 

operate in the various systems. In fact, partner 

agencies often need to understand what 

services are available and who the providers 

are in each system.

To understand the array of local services and 

overcome the barriers to coordinating services 

to meet the needs of this population of 

pregnant woman and their infants, prospective 

collaborative partners from each of the primary 

systems of health care, substance abuse 

treatment, mental health, child welfare, and 

dependency and Family Drug Courts need to 

know what questions to ask when they begin 

their joint planning. These questions must be 

identified regardless of whether the potential 

partners’ intent is to initiate, expand, or truly 

integrate their services and systems.
19

Building the Collaborative 

Team10

To build and foster cross-system collaboration, 

building an effective coordinating team 

is of paramount importance. This section 

presents a description of a collaborative team. 

Ideally, collaborative teams include a steering 

committee, a core team, and work groups. 

The Collaborative Team

Preferably, the state, tribe, or local government 

creates the collaborative team and endows 

it with the capacity and resources needed to 

support and sustain its major initiatives. A welldesigned collaborative team can support the 

plans set in motion and ensure goals are met, 

especially if the team convenes on a regular and 

predictable basis and keeps its focus on systems 

change, improved outcomes, and sustainability. 

One way to organize the team is as follows:

§ Steering Committee—This committee 

oversees and designates the members of 

the core team (defined below); facilitates 

necessary cabinet, council, commission, 

and legislative policy changes;11 and works 

to remove system barriers. The committee 

consists of multidisciplinary top executives, 

directors, and leaders across each of the 

collaborating entities. Participation and 

presence of key decision makers will 

increase the efficiency and effectiveness of 

the meetings.

TIP: Keep steering committee leaders engaged 

by informing members of the collaborative 

team’s progress so that they are prepared to 

pave the way for necessary change.

10 For more information on developing a collaborative team and structure, see Screening and Assessment for Family 

Engagement, Retention, and Recovery (SAFERR) https://www.ncsacw.samhsa.gov/resources/SAFERR.aspx

11 If using federal funding, these actions must be taken in compliance with Section 503(b) of the Departments of Labor, Health 

and Human Services, and Education, and Related Agencies Appropriations Act, 2016 (S. 1695). Section 503(b) provides that 

no federal funds from the HHS annual appropriations act may be used to pay the “salary or expenses of any grant or contract 

recipient, related to any activity designed to influence legislation or appropriations pending before the Congress or any State 

legislature.” https://www.congress.gov/bill/114th-congress/senate-bill/1695

§ Facilitator—Guides the team in decision 

making. The facilitator role can be fulfilled by 

bringing in an outside facilitator, appointing 

representatives from the different systems 

to conjointly fulfill the role, or appointing 

representatives from the different systems to 

rotate in the facilitator role. These strategies 

can help the systems share responsibility, 

while also avoiding the perception that 

the initiative is being “run” by one agency. 

Having system representatives fulfill the 

facilitator role requires the representative to 

be aware and understand his or her multiple 

and potentially conflicting roles. In the 

facilitator role, system representatives must 

diligently maintain the distinction between 

their role as the facilitator and as the system 

representative. When the boundaries of 

these roles are delineated and respected, 

others will be more inclined to trust and 

respect the boundaries as well. Ideally, the 

facilitator role, or the various configurations 

that can fulfill the facilitator role, requires 

familiarity with the subject matter and how 

the systems operate (Pennsylvania State 

University, 2015).

TIP: Facilitate decision making among 

multiple systems by appointing a formal 

facilitator. Facilitating a multidisciplinary 

team requires skills that differ from those 

required to direct single-agency work groups; 

stakeholders from different disciplines do not 

have jurisdiction over each other, and decision 

making by decree or majority rule will not 

work in these situations.

§ Core Team—Responsible for implementing 

policy changes at each organization. The 

core team is multidisciplinary and consists of 

mid-management representatives from each 
20

collaborating entity in addition to consumers, 

advocates, and representatives of other 

organizations, as appropriate.

TIP: Include no more than six to eight 

individuals in the core team. Core Team 

members should have sufficient authority and 

flexibility to approve agency-level practice and 

policy changes to sustain the collaborative 

team’s momentum by achieving “quick wins.”

§ Work Groups—Created by the steering 

committee to address priorities of the 

collaborative initiative. Work groups include 

members of the core team and additional 

key stakeholders, such as providers and 

practitioners, consumers and advocates.

TIP: Give your work groups specific 

challenges they can address by using firsthand knowledge from key stakeholders 

regarding effective tools and strategies, such 

as devising a communication protocol.

This type of structure can be used at the state, 

tribal, and local levels. At the local level, for 

example, the health department might convene 

the collaborative team. Ideally, all of these 

entities work closely together to accomplish 

jointly identified goals and shared priorities for 

improving practice and policy.

This structure helps ensure:

§ Sustainability of the initiative through the 

authority and endorsement of the steering 

committee;

§ Communication through accountability 

in the hierarchical and peer-to-peer 

relationships of the core team;

§ Regional broad-level buy-in through 

the participation and investment of the 

diverse stakeholders who make up the 

work groups; and

§ Internally supported change through 

the investment and commitment of 

multiple systems to achieve collaboratively 

defined outcomes.

Cross-system teams must consider several steps 

as they prepare to engage in collaborative 

planning. These steps, (1) setting the stage for 

collaboration, (2) engage key stakeholders and 

establish work groups, (3) define shared goals, 

and (4) identify strategies and jointly monitor 

outcomes, are discussed below. Questions 

are posed to guide the purpose and outcome 

of each step. Appendix 1: Facilitators Guide

includes a facilitator’s guide and a set of tools 

to help the development of a work plan, based 

on prioritization of identified goals. The tools 

include a Cross-System Guide, to develop a 

baseline understanding of areas of strength 

and opportunities for improvement, and five 

System-Specific Guides, to understand the 

context of the initiative from multiple points of 

view. For instance, each system’s perspective 

of the “primary” client (e.g., mother, infant, 

or family) differs. The identified “primary” 

client often drives the system’s response and 

goal. For example, the MAT provider may 

consider the mother as the primary client, 

with interventions targeted solely at her. In 

comparison, the infant’s neonatologist or 

pediatrician may identify the infant as the 

primary client. Although each service provider 

must provide services within their scope of 

practice, understanding the impact of opioid 

use disorders on the mother and infant as well 

as what services and supports are needed 

for optimal outcomes requires a mutual 

understanding of the involved systems. The 

guides can provide the necessary background 

for teams before making decisions about—and 

committing valuable resources to—statewide 

practice and policy changes.

STEP 1: Setting the Stage for Collaboration

Once the core team has been formed, some 

general fact gathering and sharing by all team 

members is necessary so that each member 

understands:

§ What practices and policies are in place in 

each team member’s service system and in 

the other service systems;

§ Partner mandates and priorities that are 

likely to affect, and possibly limit, their level 

of involvement;
21

§ The terminology that each team member’s 

organization uses most frequently and how 

the organizations define these terms (e.g., 

“treatment”);

§ The baseline resources, resource gaps, and 

barriers in each system; and

§ What needs to be addressed and improved, 

particularly from the perspective of mothers, 

children, and family members, to provide the 

necessary care. 

STEP 2: Engage Key Stakeholders and Establish 

Work Groups

To determine which partners should be 

involved in the initiative, an assessment of 

the current level of collaboration is helpful. 

Questions to answer include: Who is 

currently working on the issue being tackled? 

What does each of these individuals or 

organizations contribute? And, significantly, 

which key stakeholders are missing from the 

conversation?

Core team members on the collaborative 

team should, at a minimum, include child 

welfare professionals, key dependency court 

and family drug court professionals, mental 

health providers, Medicaid officials, and 

healthcare providers. Healthcare providers 

include office- and hospital-based obstetricians, 

pediatricians, neonatologists, primary care 

providers, hospitalists, medical social workers, 

and opioid treatment and other substance 

abuse treatment providers (including residential, 

intensive outpatient, and outpatient treatment 

providers).12, 13 Other stakeholders, including 

lead staff from agencies such as Temporary 

Assistance for Needy Families, maternal and 

child health agencies, and housing authorities, 

may also play key roles in the collaborative team.

Other potential participants include organizations 

that are unique to the community and provide 

services for this population of families, such as 

women’s or children’s health resource centers; 

early child intervention organizations; and 

clinical, financial, or legal resource centers as well 

as representation from tribes in communities 

with American Indian populations and/or tribal 

leadership. Finally, it is critical to ensure that 

pregnant women or mothers representing the 

target population have a voice in the process and 

are active participants in planning, informing, 

communicating, and collaborating. 

Key stakeholder participation in the 

collaborative team is likely to be determined by 

existing partnerships and whether the overall 

effort is intended to provide new services, 

expand existing services, or increase levels of 

service integration across systems.

STEP 3: Define Shared Goals

Every state, tribe, and community is supported 

and challenged by its own systems, issues, 

beliefs, and ideals. On occasion, the existing 

protocols, culture, and financial constraints 

may affect the collaborative team’s ability to 

be successful in coordinating their approach 

and share accountability for the outcomes. 

Therefore, each team member needs to 

evaluate how their system-specific and 

individual principles and values will lead 

practice and policy change and understand the 

perspectives that are influencing the positions 

and decisions of the other partners.

To create principles for their work together, the 

team should collectively examine and discuss 

fundamental questions, such as:

§ What is each represented agency’s role in 

achieving shared priorities and outcomes 

(e.g., How does child welfare services 

support parent recovery? How do treatment 

providers for parents support child safety 

and permanency and family well-being?)

12 Dependency courts refer to courts that handle dependency cases involving children and youth under 18, including child 

maltreatment (see https://www.childwelfare.gov/pubPDFs/cwandcourts.pdf).

13 Family Drug Courts (also referred to as Family Dependency Treatment Courts, Family Treatment Courts, Dependency Drug 

Courts, and Family Treatment Drug Courts) use a multidisciplinary approach, recognizing that their clients (i.e., parents, children, 

and families who enter the Family Drug Court) often face a range of challenges in addition to a substance use disorder (see 

http://www.cffutures.org/files/publications/FDC-Guidelines.pdf).
22

§ What does each team member believe 

about the nature of substance use and 

substance use disorders?

§ Do team members agree on the markers of 

effective practice and service delivery? What 

are those markers?

§ How is “best interest” defined for infants? 

For mothers? For families? Do mothers have 

sufficient input in determining this?

§ What do team members or policy leaders 

believe about the use of MAT for women 

who are pregnant or breastfeeding?

§ What do team members believe constitutes 

recovery?

STEP 4: Identify Strategies and Jointly Monitor 

Outcomes

A crucial component of developing a coordinated 

response is the ongoing transfer of knowledge 

across professionals, agencies, and organizations. 

This knowledge transfer enables the team to 

establish and maintain a shared understanding 

of evidence-based practices for pregnant women 

with opioid use disorders and their infants from 

a multi-system perspective. To facilitate this 

knowledge transfer, the team needs to: 

§ Review the desired outcomes for each 

system by, for example, determining 

how success is defined and measured, 

identifying baseline levels for clients, and 

finding out whether better (or additional) 

indicators are available to demonstrate 

progress. For example, hospitals may 

be focused on positive birth outcomes, 

child welfare focused on child safety, and 

substance use disorder treatment agencies 

may be focused on measures of recovery.

§ Determine the metrics (e.g., number of 

pregnant women treated with MAT) that 

need to be developed and tracked to 

effectively measure success over time. This 

can include assessing what technology 

is available to track outcomes. Recent 

developments, such as electronic health 

records and Health Information Exchanges, 

can help facilitate communication across 

systems and, ultimately, be an avenue to 

measure outcomes.

§ Create a method for communicating 

progress related to key indicators (e.g., 

a report card or dashboard) to ensure 

transparency and promote accountability 

for results.

§ Review the plan for sustaining change and 

determine, for example, how the team 

will document, maintain, and build on the 

collaboration’s institutional knowledge.

To facilitate the development of a work plan 

that addresses the needs of pregnant women 

with opioid use disorders and their infants, see 

Appendix 1: Facilitator’s Guide for the tools.

Concluding Thoughts

This report provides practical, evidenceinformed guidance to help collaborative, crossdisciplinary teams support effective, healthy 

outcomes for pregnant women with opioid 

use disorders and their infants. This guide 

underscores the potential impact of opioid 

use during pregnancy and the importance of 

a systems-level approach that is driven and 

endorsed by state and tribe leadership to 

mobilize resources and facilitate cross-system 

practice and policy changes. It also provides 

a framework for communities to take stock 

of their current policies and identify areas for 

improvement. It is the view of the national 

panel of experts that informed this guide that 

top-down approaches that do not include the 

views of local practitioners, other professionals, 

and families will likely lead to resistance and 

uneven implementation. For collaborative 

practices to be successful, all parties involved 

must witness and experience the benefits.

It is beyond the scope of this guidance to 

adequately address the entire range of topics 

related to pregnant women with opioid use 

disorders and their families; however, it is 

important to highlight some additional focus 

areas that states, tribes, and communities 

might want to factor into their planning and 

policy development.

Value of Prevention. For the vast majority of 

women, drug use or misuse begins long before 

they become pregnant. Therefore, key drivers 
23

for achieving healthier pregnancies and births 

and better child safety outcomes is ensuring 

women of childbearing age have better 

access to effective birth control methods14

and engaging women of childbearing age 

who have substance use disorders to seek 

treatment before they become pregnant. 

Broad community approaches to preventing 

opioid use disorders are underway in many 

states and should be expanded to target opioid 

use during pregnancy. Current community 

approaches include SAMHSA’s Strategic 

Prevention Framework Partnerships for Success, 

which seeks to target the use and misuse of 

prescription medications and heroin among 

persons ages 12–25 (SAMHSA, 2014b). 

Improved Data Collection, Management, 

and Reporting. Improved data collection 

is urgently needed to better illuminate the 

challenges these families face and to be able 

to measure the success and effectiveness 

of different interventions and approaches. 

The prevalence of substance use during 

pregnancy is often underreported, mostly 

because pregnant women feel shame and guilt, 

aggravated by the societal stigma which is so 

pervasive in most communities. Most health 

care systems do not use universal screening for 

substance use during pregnancy or delivery, 

contributing to the lack of data. Community 

responses to infant prenatal exposure, child 

welfare referrals, and case dispositions are 

also unevenly tracked. Identifying crucial 

indicators, such as referrals to child welfare 

agencies, as part of the CAPTA requirements 

and developing ways to collect information 

would strengthen responses to families and the 

use of community resources.

As we seek to learn more about how to 

respond successfully to the unique needs of 

pregnant women with opioid use disorders, 

we can draw from and build on lessons from 

the past. In this guidance document, we have 

focused on the unique needs of pregnant 

women with opioid use disorders. However, 

much of the guidance and principles provided 

are applicable to all women with substance 

use disorders and their infants. We hope that 

strengthening collaborative relationships to 

respond to this need will ensure that those 

relationships endure and offer a ready resource 

for addressing other challenges in the future.

14 Visit the ACOG website for information on contraception, including guidance on which forms of birth control are most 

appropriate, based on each woman’s needs: http://www.acog.org/Womens-Health/Birth-Control-Contraception.
24

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25

Appendix 1: Facilitator’s Guide

Appendix 1: Facilitator’s Guide

This appendix includes six guidance tools to help facilitate a careful, in-depth analysis of current 

policies, practices, resources, and training needs as related to working with pregnant women with 

opioid use disorders. Included is a Cross-System Guide to develop a baseline understanding of 

areas of strength and opportunities for improvement across the systems. As the collaborative 

team forms and begins to determine the roles and responsibilities of each partner, members need 

to evaluate their own practices and areas that need improvement. Five System-Specific Guides 

(mother’s medical providers, infant’s medical providers, substance use treatment and medicationassisted treatment providers, child welfare, and dependency court) are provided to facilitate 

understanding the initiative from multiple points of view. These guides can provide teams with 

needed background information before they make decisions about, and commit valuable resources 

to, statewide practice and policy changes. 

Role of the Facilitator: A facilitator leads the team in using the guides. See Building the 

Collaborative Team on page 18 for additional information on the role of the facilitator.

Considerations for the facilitator and collaborative include:

§ Is the team seeking to gain a baseline understanding of policies and practices across or 

within systems?

§ How will the guides be administered? What format works best—survey, facilitated 

discussion, or a combination of methods? What are the resource implications?

§ When will the guides be administered? What will be the sequencing of the Cross-System 

and System-Specific Guides?

§ How will the results be understood and used to further the work of the collaborative? What 

are the steps following administration of the guide(s)—development of an action plan?

§ Will the guide(s) be administered multiple times to assess the progress of the team or each 

system? 

The following provides information to help answer the above posed questions. 

Overview, Cross-System Guide, and System-Specific Guides: The Cross-System Guide is 

meant to prompt the five primary systems—mother’s medical care providers, infant’s medical 

providers, substance use treatment and medication-assisted treatment providers, child welfare, 

and the dependency court—to better understand the challenges and opportunities in working 

with pregnant women with opioid use disorders and their infants. The statements posed in the 

guide present best practices in working with pregnant women with opioid use disorders and will 

challenge some professionals to rethink the scope of their current role and responsibilities and how 

these might be adjusted to better serve the needs of pregnant women with opioid use disorders 

and their families. As collaborative partners respond to the statements, a baseline “inventory” of 

practices and policies across systems will begin to emerge. Partners will also be asked to prioritize 

identified issues to facilitate development of a work plan. It is significant to remember, however, 

that even if team members are satisfied with the present status of certain practices and policies, 

these practices and policies may pose a concern or present a barrier for one of the partners. In such 

cases, the whole team will need to work to determine how to resolve these issues.

TIP: Documenting stakeholders’ responses to the statements in the guides will help clarify roles and 

communicate what each partner is able and willing to provide to support families.
26

Appendix 1: Facilitator’s Guide

While the Cross-System Guide seeks to identify challenges and opportunities across systems, the 

System-Specific Guides seek to identify a baseline “inventory” of practices and policies related to 

working with pregnant women with opioid use disorders within each system. The System-Specific 

Guides mirror the five-point intervention framework described in the subsection, Overview of 

Substance-Exposed Infants (SEI) Framework, on page 16. The statements for each system/provider 

are organized into three intervention time frames: (1) pregnancy, (2) time of birth, and (3) postnatal 

period and after. The guide for the mother’s medical providers includes a fourth intervention 

point—pre-pregnancy. These time frames reflect the order in which a pregnant woman typically 

comes into contact with each system, beginning with a visit to her obstetrician/gynecologist 

during pregnancy. Similar to the Cross-System Guide, the statements in the System-Specific Guides 

represent best practices in working with pregnant women with opioid use disorders. The SystemSpecific Guides are composed of the following:

1. Mother’s Medical Care Providers: This includes the array of health care systems that provide 

medical care to the mother. Professionals from these systems include the mother’s obstetrician, 

nurses, and other professionals involved in the mother’s care during pregnancy and during 

the labor and delivery at the hospital. The team at the birth hospital can also include the 

anesthesiologist, hospital social worker, lactation specialist, and various nurses (e.g., labor and 

delivery; aftercare). 

2. Infant’s Medical Care Providers: This includes the range of health care systems that provide 

care for the infant. Professionals from these systems can include neonatologists, nurses, or other 

specialists who work in the neonatal intensive care unit (NICU); the pediatrician selected by the 

mother prior to the delivery; and the pediatrician assigned by the birth hospital (or the “on-call” 

pediatrician).

3. Substance Abuse Treatment and Medication-Assisted Treatment Providers: The substance 

use treatment system consists of different types of substance use treatment providers 

that offer a range of services (e.g., counseling, outpatient treatment, residential treatment, 

educational and vocational services, and medication-assisted treatment). Depending on the 

type of provider and the scope of services provided by each provider, professionals can include 

treatment counselors, case managers, peer support specialists, and physicians or nurses who 

specialize in substance use treatment. Substance abuse treatment and medication-assisted 

treatment providers can be categorized into three broad groups:

§ Substance Use Treatment Providers: These providers offer a range of services that can 

include prevention (e.g., education and community awareness), outpatient treatment, 

residential treatment, and case management. Some treatment facilities provide medicationassisted treatment, either as a Substance Abuse and Mental Health Services Administration 

(SAMHSA)-certified opioid treatment program (see below for more information) or can have 

(informal or formal) relationships with medication-assisted treatment providers. 

§ Opioid Treatment Programs (OTPs): These are SAMHSA-certified providers. Certification 

requirements include a medical director who is licensed to practice medicine and has 

experience in addiction medicine and delivery of or coordination of behavioral health and 

other services in conjunction with the prescription and administration of medications. The 

delivery or coordination of psychosocial services can be configured differently, with some 

OTPs physically housed with or representing a segment of the services available through 

a substance use treatment provider, and other OTPs who rely on (informal or formal) 

agreements to ensure delivery of these services.
27

Appendix 1: Facilitator’s Guide

§ Independent Physicians: These are individual physicians who operate independently from 

OTPs. They include physicians and/or other medical professionals who prescribe medications 

for the treatment of opioid use disorders. The different medications carry different licensing 

and certification requirements (see Appendix 4: Key Features of Medications Approved for 

Treating Opioid Use Disorders).

4. Child Welfare Services: The child welfare system encompasses a range of services and 

professionals involved in multiple phases of a child welfare case. Typically, the phases entail 

(1) receipt of the initial child abuse/neglect report; (2) an investigation or assessment of the 

allegations to determine child risk and safety, whether the child should remain in the care of 

the parent(s), whether ongoing services are necessary, and what type of services are necessary 

(e.g., in-home or out-of-home care for the child and whether oversight by the dependency court 

is needed); (3) ongoing case management to support the family in achieving goals, including 

reunification; and (4) permanency planning (e.g., adoption, legal guardianship, emancipation). 

Usually, a different social worker is assigned to each phase. Multiple social workers can also be 

assigned at a single point in time, such as during phase transition, or permanency planning can 

occur concurrently with reunification planning. 

5. Dependency Courts: The dependency court system makes judicial decisions regarding children 

who have been removed from parental care. Decisions are based on the Adoption and Safe 

Families Act, the federal child welfare legislation regarding children who have been removed 

from their parents. A variety of professionals comprise the dependency court system. These 

include the judge, parent’s attorney, child’s attorney, the attorney who represents child welfare, 

and other professionals who come together at different hearings to determine whether a child 

has been rightfully removed from parental care, whether the abuse/neglect allegations should 

be substantiated, and decisions on reunification and other permanency options.

Which Guide Should Be Used? The guides can be used in a variety of ways and facilitated through 

different methods (e.g., a web-based survey or data collection tool or as part of a guided discussion), 

such as by:

§ Facilitating the Cross-System Guide as a Stand-Alone Tool: A collaborative team can 

complete the Cross-System Guide to understand the strengths and opportunities for 

improvement in policies and practices across systems. The results of the guide can lay the 

groundwork for a collaborative action plan.

§ Facilitating Both the Cross-System and System-Specific Guides: Following completion of 

the Cross-System Guide, the team can choose to have each partner complete its System-Specific 

Guide to identify areas of strength and opportunities for improvement within each system. The 

results of the System-Specific Guides can form the basis for action plans specific to each system 

that can inform the larger systemic action plan. Or, the results of the Cross-System Guide can 

help narrow the scope of the area that the team wants to prioritize. For instance, if priority 

and preferred access for pregnant women to medication-assisted treatment is identified as a 

priority area, the team can decide to focus on the guide intended for substance abuse treatment 

and medication-assisted treatment providers. Or, if the care of prenatally exposed infants is 

identified as an area needing discussion, the team can focus on the guides geared toward the 

infant’s medical care providers and child welfare services. Used together, the Cross-System and 

System-Specific Guides can build the foundation for a comprehensive action plan that addresses 

the larger systemic issues as well as the issues specific to each individual system. For more 

information on recommended steps to facilitate a collaborative process, see Figure 1 below and 

A Guide for Collaborative Planning on page 17.
28

Appendix 1: Facilitator’s Guide

§ Facilitating the System-Specific Guides as a Stand-Alone Tool: The System-Specific Guides

can be completed prior to or as a stand-alone from the Cross-System Survey. This configuration

may be most appropriate for systems that are seeking to improve policy and practice in working

with parenting and pregnant women with opioid use disorders but have not yet formulated

a team approach. The results of the guide can then be used to examine and introduce policy

and practice within the individual system and can serve as a launching point to facilitate a

collaborative process.

Understanding the Results: To understand the level of agreement or extent to which the best 

practices discussed in the guides permeate the system, assign numerical values to the responses. 

The responses for the level of agreement are based on a Likert scale from 1–3, with No assigned a 

numerical value of 1, To Some Extent assigned a numerical value of 2, and Yes assigned a numerical 

value of 3. Items that receive Not Sure are assigned a score of 0 and are not included in the 

calculations. Simple calculations will result in a mean score. 

A potential way of understanding the level of agreement on the extent that a practice exists is 

to examine mean scores by the seven topic areas (perspective, approach, coordination, service 

gaps and daily practice, reimbursement and access, training and staff development, and quality 

and outcome monitoring) that the Cross-System Guide is organized around. Areas that receive a 

higher mean may indicate a higher level of agreement and perhaps a lower likelihood that action is 

needed. Helpful tips for understanding the responses include: 

§ Focus on areas that reflect a lower mean, as this may indicate that action in that particular

area is necessary.

§ Focus on areas that reflect a high degree of uncertainty (e.g., a large number of respondents

indicated Not Sure). Areas of uncertainty require further exploration to understand what is

driving the uncertainty. In this situation, it would be helpful to examine the responses to

the individual statements within the identified area to facilitate the discussion.

Figure 1: Sample Collaborative Process
29

Appendix 1: Facilitator’s Guide

§ Understand that the level of agreement may not correlate with how respondents prioritize 

each item. For instance, in the Cross-System Survey, the understanding and acceptance of 

medication-assisted treatment as an evidence-based treatment for pregnant women may 

result in a high degree of uncertainty, as systems may not be aware of the other systems’ 

approaches in working with pregnant women with opioid use disorders. At the same 

time, respondents may rate the issue as an area that requires immediate action as a step 

towards removing barriers for pregnant women in accessing medication-assisted treatment. 

Similarly, respondents may be uncertain of the extent to which policies and protocols 

that facilitate access to medication-assisted treatment permeate the larger system. In this 

situation, respondents may also indicate that immediate action is necessary. 

Another example can involve policies or practices that respondents identify as not existing on a 

wide scale (e.g., respondents indicate a low level of agreement), yet they may indicate that the issue 

does not require immediate action. For instance, respondents may indicate that a trauma-informed 

approach in working with pregnant women with opioid use disorders does not exist across systems. 

Yet, respondents may rate the issue as having a lower priority for action. This does not mean that 

the team feels that the issue is unimportant. Instead, team members are able to prioritize identified 

gaps and barriers to inform the development of an action plan. 

TIP: Having an understanding of both the level of agreement and the priority associated with each 

practice or policy area will facilitate the development of an action plan.

Recognize that the range of respondents who complete the guides can impact the overall findings. 

For instance, a Cross-System Guide that is completed by a group that is composed of mostly child 

welfare representatives may result in a high level of uncertainty for the best practice items related 

to substance use treatment. Since each system is composed of a variety of diverse professionals, 

understanding the range of professionals who complete the System-Specific Guides is also helpful. 

For instance, the child welfare specific guide includes best practices in investigating reports involving 

prenatal exposure to opioids. If the guide is completed by a group that has a small number of 

investigating social workers, there may be a high level of uncertainty found for the items related 

to responding to a child abuse/neglect allegation. “Unsure” responses will direct the team to areas 

where more information is needed. Included with the guides are sample demographic questions that 

can be used to understand the range of respondents. 

Operationalizing the Results: Using the guides will result in a baseline understanding of strengths 

and challenges that can be used to inform an action plan. The action plan can be further informed 

through other diagnostic processes; some collaborative work groups have used case studies, system 

walk-throughs, or resource mapping. These exercises help to further illuminate:

§ What needs to be addressed and improved;

§ Gaps and barriers in existing programs, services, and resources; and

§ Resources and action steps needed to close the gaps and eliminate the identified barriers.
30

Appendix 1: Facilitator’s Guide

Conducting a system walk-through or collaborative examination of a case study can illuminate the 

gaps in services from the perspective of the mother. A walk-through can entail a literal (e.g., physical) 

walk-through of the experience of a pregnant woman as she goes through each of the systems, or it 

can entail a simulated walk-through, with stakeholders sharing their experience and knowledge of 

what happens at the client level. The purpose of a walk-through is to identify points in the process in 

which a pregnant woman may encounter roadblocks (e.g., she indicates that she needs substance use 

treatment at a prenatal appointment but is not connected to treatment services). 

Examining a case study can also serve the same purpose. It is helpful to use a case that is reflective 

of each community’s issues. If possible, an actual case (that has identifying information redacted), 

should be used. The walk-through and case study can be organized by different intervention points: 

prenatal/pregnancy, labor and delivery, postpartum, and beyond (see the Substance-Exposed Infants 

[SEI] intervention Framework described on page 16 for additional information). 

Resource mapping can help align resources and policies to the goals identified in the action plan 

(University of Minnesota, 2005). For instance, the results of the Cross-System Guide might identify 

the screening and assessment of prenatally exposed infants as a priority area. Resource mapping can 

help identify the degree to which screening and assessment practices reach women and infants in the 

community, the funding sources available for screening and assessment, barriers or capacity issues, 

and related legislation or policies that influence practices. It may be helpful to organize the mapping 

process by the SEI intervention framework. 

Instructions to Complete the Guides: The statements represent a policy or practice issue. 

Respondents are to indicate their agreement with No, To Some Extent, Yes, or Not Sure and to prioritize 

each statement with Immediate, 2 years, or 3–5 years. 

Respondents are also encouraged to include strengths, challenges, and ideas for improvement (in the 

space provided for Recommendations/Comments), while answering the questions to facilitate the 

team’s development of mission and goals. When reviewing each question, have respondents consider 

the following: 

§ The extent that the policy or practice is occurring.

– Cross-System Guide: The intent is to come to a general understanding of the underlying 

policies and practices across disciplines that shape the larger systemic response to pregnant 

women with opioid use disorders. Respondents should answer on behalf of the state, tribe, 

or local jurisdiction (e.g., the community that the collaborative encompasses). For instance, 

when responding to whether a formal system of care coordination (e.g., informationsharing agreements) is in place, respondents should respond based on their experience and 

knowledge of the systemic response. Respondents are encouraged to include examples of 

practices or policies that cannot be generalized to the larger system in the space provided for 

recommendations and comments or to share them as part of discussions. 

– Systems-Specific Guides: The intent is to understand the policies and practices within each 

discipline’s sphere of practice. Respondents should base their responses on their experience 

and knowledge of the individual system and individual organizations or facilities that 

they represent. This will help identify innovative strategies and practices that are being 

implemented at the local level. 
31

Appendix 1: Facilitator’s Guide

TIP: The guides present a range of policies and practices related to working with pregnant women with 

opioid use disorders. At the onset of the collaborative effort or during the first administration of the 

guide(s), facilitators can expect push back from stakeholders, particularly on items that are perceived 

as unattainable, or the gold standard. Re-assessing stakeholders’ responses to these items as the team 

progresses is particularly informative of the collaborative’s growth (see Measuring Progress, below). 

§ Are respondents able to answer the posed questions? If not, who can answer it and is that 

person or group at the table?

§ Are respondents satisfied with the practice that the answer implies? If not, is changing the 

practice solely within the respondents’ control?

§ If change requires collaboration, who is needed to make the change?

Measuring Progress: The Cross-System Guide and System-Specific Guides will give respondents a 

baseline understanding, or measurement, of policies and practices related to working with pregnant 

women with opioid use disorders. These guides can also be used multiple times to measure the 

team’s progress. For instance, the Cross-System Guide may identify access to medication-assisted 

treatment as a major barrier and priority area. The Cross-System Guide can then be administered 

later in time (e.g., 6–12 months) to assess what progress has been made. Likewise, if training is 

identified as a barrier and priority area, the System-Specific Guides can be re-administered to 

determine what progress has been made.
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Appendix 1: Facilitator’s Guide

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33

Appendix 1: Facilitator’s Guide, Guide 1: Cross-System Guide 

Guide 1: Cross-System Guide

Introduction: The statements in this guide are to help establish a baseline understanding of 

the practices and policies used across systems in working with pregnant women with opioid use 

disorder. Having a baseline understanding of the practices and policies will help teams evaluate 

the strengths and challenges they face, which in turn will help them prioritize and develop goals for 

the collaborative. The statements represent a policy or practice issue, which are organized by seven 

content areas: Perspectives, Approach, Coordination, Reimbursement and Access, Service Gaps and 

Daily Practice, Training and Staff Development, and Quality and Outcome Monitoring. 

Who Should Complete This Guide? This guide should be completed by members in the five 

primary systems: the mother’s medical care providers, the infant’s medical providers, substance use 

treatment and medication-assisted treatment providers, child welfare, and the dependency court. 

Ideally, gathering responses from the five primary systems will result in a broader understanding. 

However, guides completed by representatives of only some of the systems are still helpful. The 

analysis will need to take into account the distribution of responses from each system.

I. Cross-System Guide

Demographics

Primary System

 Mother’s Medical Provider

 Substance Use Treatment and Medication-Assisted Treatment

 Infant’s Medical Provider

 Child Welfare

 Family Dependency Court

 Public Health (e.g. Early Intervention, Maternal Health)

 Other (describe)

If you represent Mother’s Medical Provider, select which best represents your role

 OB/GYN

 OB/GYN with board specialty in addiction medicine 

 Nurse (prenatal care)

 Nurse (labor and delivery)

 Anesthesiologist

 Lactation Consultant

 Other (describe; e.g. Hospital Social Worker)

If you represent Substance Use Treatment and Medication-Assisted Treatment, select all that apply

 Detox

 Outpatient

 Intensive Outpatient

 Residential Treatment

 Medication-Assisted Treatment

 Other (describe)

If you represent Infant’s Medical Provider, select which best represents your role

 Pediatrician

 Neonatologist

 NICU Nurse

 Other (describe)

If you represent Child Welfare, select which best represents your role

 Child Protection (Emergency Response)

 Family Reunification/Maintenance (Case Carrying)

 Adoption/Legal Guardianship(Permanency Planning)

 Tribal

 Other (describe)

If you represent Dependency/Family Court, select which best represents your role

 Judge

 Child Attorney

 Parent Attorney 

 Child Welfare Attorney

 Child Advocate (e.g. CASA, GAL)

 Other (describe)

If you represent Public Health (e.g. Early Intervention, Maternal Health), select which best represents your role

 Home Visitor

 Public Health Nurse

 Outreach and Education

 Other (describe)
34

Appendix 1: Facilitator’s Guide, Guide 1: Cross-System Guide 

I. Cross-System Guide (cont.)

Level of Agreement Priority 

for Action

Recommendations/

Comments

Perspective 

1. Medication-assisted treatment 

is understood and accepted as 

an evidence based treatment 

for pregnant women who have 

an opioid use disorder.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

Approach

2. Policy and protocols that 

facilitate access to medicationassisted treatment for pregnant 

women with opioid use disorders 

are in place.

In the space provided for 

recommendations/comments, 

describe protocols, practices, 

etc. that facilitate or discourage 

pregnant women from accessing 

medication-assisted treatment 

(e.g. priority access; policies that 

state that pregnant women should 

not receive medication-assisted 

treatment; mutual aid groups that 

do no support medication-assisted 

treatment)

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

3. Our approach is guided by 

principles that are evidence 

based and trauma informed.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

4. Our approach is culturally 

responsive. No To Some 

Extent Yes Not 

Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)
35

Appendix 1: Facilitator’s Guide, Guide 1: Cross-System Guide 

I. Cross-System Guide (cont.)

Level of Agreement Priority 

for Action

Recommendations/

Comments

Coordination 

5. Our agency has a good 

working relationship with 

the other key agencies.

In the space provided for 

recommendations/comments, 

describe areas of strength and 

opportunities for improvement.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

6. A formalized system of care 

coordination between systems 

is in place (e.g., information 

sharing agreements, MOUs).

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

Service Gaps and Daily Practice

7. Pregnant women with substance 

use disorders are identified No To Some Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

8. Medication-assisted treatment 

for pregnant women is available. No To Some Extent Yes Not 

Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

9. Specialized prenatal care 

(e.g., obstetricians who are 

knowledgeable in addiction 

medicine) is available for 

pregnant women with opioid use 

disorders.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)
36

Appendix 1: Facilitator’s Guide, Guide 1: Cross-System Guide 

I. Cross-System Guide (cont.)

Level of Agreement Priority 

for Action

Recommendations/

Comments

Service Gaps and Daily Practice (cont.)

10. The appropriate levels of care 

(e.g., residential substance use 

treatment programs) for pregnant 

women are available. 

In the space provided under 

Recommendations/Comments, 

describe whether residential 

treatment programs are available 

for mothers and their infants/

children.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

11. The full range of services 

(e.g., individual and group 

counseling, residential, etc.) is 

provided in conjunction with 

medication-assisted treatment.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

12. Newborns and infants who 

have been prenatally exposed 

to opioids are identified.

No To Some 

Extent Yes Not 

Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

13. Ongoing care and monitoring 

is available for infants who 

have been prenatally exposed 

to opioids.

No To Some 

Extent Yes Not 

Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)
37

Appendix 1: Facilitator’s Guide, Guide 1: Cross-System Guide 

I. Cross-System Guide (cont.)

Level of Agreement Priority 

for Action

Recommendations/

Comments

Reimbursement and Access

14. Policies are in place to assist 

pregnant women who have 

financial obstacles when trying 

to access and maintain services 

for the treatment of opioid 

use disorders (e.g., medicationassisted treatment; outpatient or 

residential treatment; individual 

and group counseling; other 

services).

In the space provided under 

Recommendations/Comments:

• Describe whether the point in 

time (e.g., pregnancy, following 

birth, postpartum) or case 

specifics (e.g., infant removed 

from parental care) affect access.

• Describe how medicationassisted treatment and other 

substance use treatment 

services are made available 

(Medicaid, insurance exchanges, 

other publicly funded programs, 

etc.). 

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

15. Priority and preferred access* 

to substance use treatment and 

medication-assisted treatment 

for pregnant women is enforced. 

*As required by the Substance 

Abuse Prevention and Treatment 

Block Grant and opioid treatment 

program certification standards.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

16. There are policies in place to 

address funding obstacles in 

providing ongoing care (e.g., 

following hospital discharge) to 

infants who are prenatally exposed. 

In the space provided under 

Recommendations/Comments, 

describe the policies, practices, etc.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)
38

Appendix 1: Facilitator’s Guide, Guide 1: Cross-System Guide 

I. Cross-System Guide (cont.)

Level of Agreement Priority 

for Action

Recommendations/

Comments

Training and Staff Development

17. The core service providers (i.e., 

mother’s medical providers, 

infant’s medical providers, 

substance use and medicationassisted treatment, child welfare, 

and dependency court) are 

knowledgeable on the treatment 

of opioid use disorder in 

pregnancy and on the care 

and treatment of prenatally 

exposed infants.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

Quality and Outcome Monitoring

18. Partners have a shared 

understanding of outcomes 

that includes both the mother 

and the infant 

(e.g., the overall goal includes mother, 

infant, and family well-being).

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

19. Data is tracked and 

shared between systems 

to monitor outcomes.

In the space provided under 

Recommendations/Comments, describe 

how data is shared (e.g., Prescription 

Drug Monitoring Programs).

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

20. Programs and service 

providers have implemented 

quality assurance methods.

No To Some 

Extent Yes Not 

Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)
39

Appendix 1: Facilitator’s Guide, Guide 2: Mother’s Medical Providers

Guide 2: Mother’s Medical Providers

Introduction: The statements in this guide are to help establish a baseline understanding of the 

practices and policies used within the systems to which the mother’s medical providers belong. The 

statements are grouped into four time frames: pre-pregnancy, pregnancy, labor and delivery, and 

postpartum and beyond. Having a baseline understanding of the practices and policies will help 

teams evaluate the strengths and challenges specific to the mother’s medical care

Who Should Complete This Guide? The mother’s medical care providers should complete this 

guide; these include the obstetrician/gynecologist (OB/GYN) and other professionals involved in 

her care. Other professionals include nurses who work with the OB/GYN throughout the prenatal 

period, anesthesiologists, and others who comprise the labor and delivery team at the birth 

hospital.

II. Mother’s Medical Providers

Level of Agreement Priority for 

Action

Recommendations/

Comments

Pre-Pregnancy 

1. All women of childbearing age

are routinely screened for 

substance use, including opioid 

use and abuse at routine visits 

(e.g., primary care, well-woman, 

and family planning visits).

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

2. Women identified to be using 

opioids are educated about the 

risk of use during pregnancy 

and offered contraceptives. 

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

3. Women identified to be misusing 

or dependent on opioids are 

linked to treatment services.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

Pregnancy

4. All pregnant women are 

screened for substance use (e.g., 

universal screening vs. 

selective screening). 

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)
40

Appendix 1: Facilitator’s Guide, Guide 2: Mother’s Medical Providers

II. Mother’s Medical Providers (cont.)

Level of Agreement Priority for 

Action

Recommendations/

Comments

Pregnancy (cont.)

5. Staff are nonjudgmental and 

supportive of pregnant women 

with opioid use disorders.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

6. Staff understand and are 

supportive of medicationassisted treatment as an 

evidence-based treatment 

for opioid use disorders 

during pregnancy.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

7. Protocols and screening tools 

are in place to determine how 

substance use during pregnancy 

is identified (e.g., SBIRT-Screening, 

Brief Intervention and Referral to 

treatment).

In the space provided under 

Recommendations/Comments, 

describe the protocols, what tools 

are used, etc.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

8. Women are informed about our 

screening and testing policies 

at the first prenatal visit and on 

how the information will be used 

(e.g., mandated reporting under 

criminal and civil child welfare 

laws).

No To Some 

Extent Yes Not 

Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)
41

Appendix 1: Facilitator’s Guide, Guide 2: Mother’s Medical Providers

II. Mother’s Medical Providers (cont.)

Level of Agreement Priority for 

Action

Recommendations/

Comments

Pregnancy (cont.)

9. Protocols are in place to ensure 

that women are referred to 

medication-assisted and other 

substance use treatment services 

(e.g., SBIRT).

In the space provided under 

Recommendations/Comments, 

describe policies, protocols, etc., 

that facilitate access to treatment 

(e.g., safe harbor legislation).

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

10. Specialized prenatal care 

is available (e.g., OB/GYNs who are 

knowledgeable in working with 

pregnant women with opioid use 

disorders).

In the space provided under 

Recommendations/Comments, 

describe how specialized prenatal 

care and other services are 

provided (e.g., specialty clinics).

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

11. Protocols are in place to 

coordinate services and 

share information with the 

mother’s medication-assisted 

treatment and other substance 

use treatment services (e.g., 

information on medication doses 

is shared).

No To Some 

Extent Yes Not 

Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

12. Programs and services are in 

place to help reduce the fetus’s 

exposure to HIV and other 

communicable diseases.

No To Some 

Extent Yes Not 

Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)
42

Appendix 1: Facilitator’s Guide, Guide 2: Mother’s Medical Providers

II. Mother’s Medical Providers (cont.)

Level of Agreement Priority for 

Action

Recommendations/

Comments

Pregnancy (cont.)

13. The mother’s birth plan includes 

considerations* specific to opioid 

use disorders. 

*Considerations include preparing 

the mother for the potential 

impact of prenatal exposure on 

the newborn and supporting and 

preparing the mother to cope 

with safely taking any needed 

medication for pain management 

during the labor and postpartum 

phases.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

14. Decisions are made with the 

woman’s input. No To Some Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

15. Protocols are in place to make a 

child welfare referral if a pregnant 

woman has other children and 

safety concerns exist.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

Birth

16. The labor and delivery 

hospital’s protocol on screening 

for opioid use (e.g., drug testing)

includes asking the mother 

for permission.

In the space provided under 

Recommendations/Comments, 

briefly describe the protocol 

(e.g., all women are screened, or 

if universal screening is not the 

protocol, what guides decisions 

on who is screened?).

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

17. The labor and delivery hospital 

staff know how to address the 

needs of women with opioid 

use disorders (e.g., pain 

management, caring for a 

newborn who has been prenatally 

exposed, and breast-feeding 

guidelines).

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)
43

Appendix 1: Facilitator’s Guide, Guide 2: Mother’s Medical Providers

II. Mother’s Medical Providers (cont.)

Level of Agreement Priority for 

Action

Recommendations/

Comments

Birth (cont.)

18. The labor and delivery hospital 

staff support mother–infant 

bonding for cases involving 

prenatal opioid exposure (e.g., 

rooming together, breast-feeding).

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

19. A referral* is made to 

child welfare in situations 

involving newborns who 

are prenatally exposed. 

In the space provided under 

Recommendations/Comments, 

describe the protocol, practice, 

etc. Is it different for cases 

involving illicit substances, 

medication-assisted treatment for 

opioid use disorders, use or misuse 

of prescription medications?

*As required by the Child Abuse 

Prevention and Treatment Act 

(CAPTA).

No To Some 

Extent Yes Not 

Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

20. Mothers are notified and 

provided support when a referral 

to child welfare is made. 

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

21. A representative from the 

birth hospital is involved in 

the development of a plan 

of safe care* (e.g., safe discharge 

to the parents’ home after the 

infant’s inpatient treatment is 

complete).

In the space provided under 

Recommendations/Comments, 

describe how the plan of safe 

care is developed, what it 

typically entails, and whether 

its development involves a 

coordinated approach with 

child welfare and other service 

providers. 

*As required by CAPTA

No To Some 

Extent Yes Not 

Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)
44

Appendix 1: Facilitator’s Guide, Guide 2: Mother’s Medical Providers

II. Mother’s Medical Providers (cont.)

Level of Agreement Priority for 

Action

Recommendations/

Comments

Birth (cont.)

22. Systems are in place to 

monitor and track cases 

involving prenatal exposure (e.g., 

birth and well-being outcomes 

that are associated with opioid use 

disorders).

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

Postnatal Period and After

23. Mothers receive contraceptive 

services, if appropriate. No To Some Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

24. Ongoing care is coordinated 

across health and social 

service systems (e.g., women are 

referred to medication-assisted 

treatment and other substance 

use treatment services, or services 

are coordinated if the woman is 

already receiving treatment).

In the space provided under 

Recommendations/Comments, 

describe how services are 

coordinated and the funding 

mechanisms that support 

coordination (e.g., Family Centered 

Medical Home, Home Visiting 

Program).

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)
45

Appendix 1: Facilitator’s Guide, Guide 3: Infant’s Medical Providers

Guide 3: Infant’s Medical Providers

Introduction: The statements in this guide are to help establish a baseline understanding of the 

practices and policies used within the systems to which the infant’s medical providers belong. The 

statements represent a policy or practice issue and are grouped into two time frames: birth and 

postnatal/beyond. Having a baseline understanding of the practices and policies will help teams 

evaluate the strengths and challenges specific to the infant’s medical care. 

Who Should Complete This Guide? The infant’s medical care providers should complete this guide; 

this includes the range of professionals responsible for the care of the infant, such as the pediatrician 

assigned by the birth hospital (or the “on-call” pediatrician), the neonatologist, the pediatrician 

selected by the mother prior to delivery, and the nurses or other specialists who work in the neonatal 

intensive care unit (NICU).

III. Infant’s Medical Providers

Level of Agreement Priority for 

Action

Recommendations/

Comments

Birth

1. We are supportive of and 

understand medication-assisted 

treatment as an evidence-based 

treatment approach for the 

treatment of opioid use disorders 

during pregnancy.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

2. We have a protocol on 

identifying and treating infants 

with neonatal abstinence 

syndrome (NAS).

In the space provided under 

Recommendations/Comments, 

describe how a NAS diagnosis is 

made and what the treatment 

includes (e.g., how are decisions 

on nonpharmacological 

and pharmacological treatment 

methods made). 

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

3. The labor and delivery hospital 

has a pediatrician available who 

is experienced in working with 

infants with NAS and women 

with substance use disorders.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)
46

Appendix 1: Facilitator’s Guide, Guide 3: Infant’s Medical Providers

III. Infant’s Medical Providers (cont.)

Level of Agreement Priority for 

Action

Recommendations/

Comments

Birth (cont.)

4. Parents are educated about 

what to expect after delivery and 

how to support the prenatally 

exposed infant in the hospital 

and at home.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

5. We support breastfeeding (when 

appropriate) and other practices 

that support mother–infant 

bonding for situations involving 

prenatal opioid exposure

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

6. A referral is made to child 

welfare* in situations 

involving newborns who 

are prenatally exposed.

*As mandated by the Child Abuse 

Prevention and Treatment Act 

(CAPTA).

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

7. Mothers are notified and 

provided support when a referral 

to child welfare has been made.

No To Some 

Extent Yes Not 

Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)
47

Appendix 1: Facilitator’s Guide, Guide 3: Infant’s Medical Providers

III. Infant’s Medical Providers (cont.)

Level of Agreement Priority for 

Action

Recommendations/

Comments

Birth (cont.)

8. We ensure that a follow-up plan 

is in place to ensure the infant’s 

safe discharge (e.g., CAPTA plan 

of safe care).

In the space provided under 

Recommendations/Comments, 

describe how the plan of safe 

care is developed, what it 

typically entails, and whether 

its development involves a 

coordinated approach with 

child welfare and other service 

providers.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

Postnatal Period and After

9. Access to specialized 

pediatric care (e.g., ongoing 

NAS treatment) and early 

intervention services are 

available and facilitated.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

10. Ongoing care is coordinated 

across health and social services. 

In the space provided under 

Recommendations/Comments, 

describe how services are 

coordinated and the funding 

mechanisms that support 

coordination (e.g., family-centered 

medical home; home visiting 

program).

No To Some 

Extent Yes Not 

Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)
48

Appendix 1: Facilitator’s Guide, Guide 3: Infant’s Medical Providers

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49

Appendix 1: Facilitator’s Guide, Guide 4: Substance Use Treatment and Medication-Assisted Treatment Providers

Guide 4: Substance Use Treatment and Medication-Assisted 

Treatment Providers

Introduction: The statements in this guide are to help establish a baseline understanding of the 

practices and policies used within the systems to which substance use treatment and medicationassisted treatment providers belong. The statements represent a policy or practice issue and 

are grouped into three time frames: pregnancy, birth, and postnatal/beyond. Having a baseline 

understanding of the practices and policies will help teams evaluate the strengths and challenges 

specific to substance use treatment and medication-assisted treatment providers.

Who Should Complete This Guide? Substance use treatment and medication-assisted treatment 

providers should complete this guide; these include (1) treatment facilities that do or do not provide 

medication-assisted treatment, (2) opioid treatment providers, and (3) independent physicians who 

provide medication-assisted treatment. The majority of the statements in this guide are applicable 

across the three general groups of substance use treatment and medication-assisted treatment 

providers.

IV. Substance Use Treatment and Medication-Assisted Treatment Providers

Level of Agreement Priority for 

Action

Recommendations/

Comments

Pregnancy

1. We coordinate care with the 

mother’s OB/GYN, other medical 

providers, and child welfare 

(e.g., sharing information on the 

mother’s progress in substance 

use treatment and in developing 

the mother’s birth plan, including 

pain management considerations).

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

2. We use validated and evidencebased assessments to determine 

the optimal treatment plan for 

pregnant women with opioid 

use disorders.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)
50

Appendix 1: Facilitator’s Guide, Guide 4: Substance Use Treatment and Medication-Assisted Treatment Providers

IV. Substance Use Treatment and Medication-Assisted Treatment Providers (cont.)

Level of Agreement Priority for 

Action

Recommendations/

Comments

Pregnancy (cont.)

3. For OTPs and 

independent physicians: We 

ensure access to 

psychosocial services.

In the space provided under 

Recommendations/Comments, 

describe how care is coordinated 

(e.g., sharing information 

on changes in the mother’s 

medication doses).

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

4. For substance use treatment 

providers who do not provide 

medication-assisted treatment:

We ensure access to 

medication-assisted treatment.

In the space provided under 

Recommendations/Comments, 

describe:

§ How care is coordinated with 

medication-assisted treatment 

providers (e.g., sharing 

information 

on parents’ progress in 

treatment), or 

§ If pregnant women are not 

referred to medication-assisted 

treatment, explain why (e.g., 

medication-assisted treatment 

providers do not accept 

pregnant women, we believe 

that medication-assisted 

treatment is unsafe for the 

infant, or that abstinence is 

the best practice for pregnant 

women).

No To Some 

Extent Yes Not 

Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)
51

Appendix 1: Facilitator’s Guide, Guide 4: Substance Use Treatment and Medication-Assisted Treatment Providers

IV. Substance Use Treatment and Medication-Assisted Treatment Providers (cont.)

Level of Agreement Priority for 

Action

Recommendations/

Comments

Pregnancy (cont.)

5. We provide priority and preferred 

access for pregnant women*.

*As required by the Substance 

Abuse Prevention and Treatment 

Block Grant and OTP certification 

standards.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

6. We support mothers to prepare 

for the birth process (e.g., pain 

management considerations 

for labor and delivery, the 

potential impact of prenatal 

opioid exposure, breastfeeding 

guidelines).

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

7. We have Safe Harbor laws, 

which can facilitate access to 

treatment by protecting against 

liability or penalty, as long as set 

conditions have been met.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

Birth

8. Our residential and other 

treatment programs have slots 

for mothers with opioid use 

disorders and their babies who 

may have neonatal abstinence 

syndrome.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)
52

Appendix 1: Facilitator’s Guide, Guide 4: Substance Use Treatment and Medication-Assisted Treatment Providers

IV. Substance Use Treatment and Medication-Assisted Treatment Providers (cont.)

Level of Agreement Priority for 

Action

Recommendations/

Comments

Birth (cont.)

9. We have a role in developing a 

plan of safe care* for the infant.

In the space provided under 

Recommendations/Comments, 

describe how the plan of safe 

care is developed, what it 

typically entails, and whether 

its development involves a 

coordinated approach with 

child welfare and other service 

providers.

*As required by the Child Abuse 

Prevention and Treatment Act 

(CAPTA).

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

Postnatal Period and After

10. Ongoing care is coordinated 

across health and social services 

(e.g., information is shared on the 

mother’s progress in treatment, 

progress in medication-assisted 

treatment, and relapse).

In the space provided under 

Recommendations/Comments, 

describe the protocols, 

strategies, etc., that facilitate care 

coordination and the funding 

mechanisms that support 

coordination (e.g., participation on 

a child safety team).

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)
53

Appendix 1: Facilitator’s Guide, Guide 6: Child Welfare

Guide 5: Child Welfare

Introduction: The statements in this guide are to help establish a baseline understanding of the 

practices and policies within the child welfare system. The statements represent a policy or practice 

issue and are grouped into three time frames: pregnancy, birth, and postnatal/beyond. Having a 

baseline understanding of the practices and policies will help teams evaluate the strengths and 

challenges specific to child welfare. 

Who Should Complete This Guide? The range of child welfare professionals should complete 

this guide; these include emergency response (investigation) social workers; case-carrying social 

workers; and those in supervisory, management, and administrative positions who work on cases 

involving pregnant women with opioid use disorders and their infants.

V. Child Welfare

Level of Agreement Priority for 

Action

Recommendations/

Comments

Pregnancy 

1. Our agency supports and 

understands medication-assisted 

treatment as an evidence-based 

approach for the treatment 

of opioid use disorders 

during pregnancy.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

2. Our agency’s policy on 

medication-assisted treatment is 

clear to the other systems. 

No To Some 

Extent Yes Not 

Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

3. Staff receive training 

on evidence-based 

treatment for substance 

use disorders, including 

medication-assisted treatment.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

4. Staff understand that 

best outcomes for pregnant 

women on medication-assisted 

treatment occur when 

they are also engaged in 

psychosocial services. 

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)
54

Appendix 1: Facilitator’s Guide, Guide 5: Child Welfare

V. Child Welfare (cont.)

Level of Agreement Priority for 

Action

Recommendations/

Comments

Pregnancy (cont.)

5. Staff understand that pregnant 

women should receive priority 

or preferred access* to publicly 

funded, medication-assisted and 

other treatment services.

*As required by the Substance 

Abuse Prevention and Treatment 

Block Grant and OTP certification 

standards. 

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

6. We can provide supportive 

intervention and safety 

assessments for women during 

pregnancy who are receiving 

medication-assisted treatment 

and other treatment services.

In the space provided under 

Recommendations/Comments, 

describe the policies, practices, 

programs, etc., that facilitate 

interventions during pregnancy 

(e.g., Safe Harbor laws, Home 

Visiting programs, Alternative/

Differential Response).

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

Birth

7. Our goal is to maintain 

the safety of the infant, 

while supporting the ability 

of mothers and infants to remain 

together.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)
55

Appendix 1: Facilitator’s Guide, Guide 6: Child Welfare

V. Child Welfare (cont.)

Level of Agreement Priority for 

Action

Recommendations/

Comments

Birth (cont.)

8. We have a protocol that 

provides clear guidance on 

child removal and opening cases 

in situations involving prenatal 

exposure to opioids (e.g., referrals 

from hospitals as required by 

the Child Abuse Prevention and 

Treatment Act [CAPTA]).

In the space provided under 

Recommendations/Comments, 

briefly describe the protocol: 

Does the guidance differ based 

on prescribed vs illicit use? Are 

workers asked to coordinate 

with other service providers (e.g., 

determining whether parents 

are in treatment, receiving 

medication-assisted treatment)? 

Do you have a unit dedicated to 

cases involving prenatal exposure?

No To Some 

Extent Yes Not 

Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

9. Our protocol on responding 

to cases involving prenatal 

exposure includes guidance on 

developing the CAPTA plan of 

safe care.

In the space provided under 

Recommendations/Comments, 

describe how the plan of safe 

care is developed, what it 

typically entails, and whether 

its development involves a 

coordinated approach with 

substance use treatment, medical, 

and other service providers.

No To Some 

Extent Yes Not 

Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)
56

Appendix 1: Facilitator’s Guide, Guide 5: Child Welfare

V. Child Welfare (cont.)

Level of Agreement Priority for 

Action

Recommendations/

Comments

Birth (cont.)

10. Our protocol on responding 

to cases involving prenatal 

exposure includes a referral* for a 

development screening and early 

intervention services for children 

ages 0–3.

* As required by CAPTA

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

11. We track the total number 

of cases involving prenatal 

exposure and their outcomes. No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

12. We support attachment 

opportunities for infants 

and mothers with opioid use 

disorders, such as rooming 

together and breastfeeding, 

when these opportunities are 

not contraindicated.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

Postnatal Period and After

13. We ensure that our assessments 

address the full range of medical, 

clinical and social support needs 

experienced by our families 

(e.g., during the investigation, to 

develop the case plan, to prepare 

the family for reunification).

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)
57

Appendix 1: Facilitator’s Guide, Guide 6: Child Welfare

V. Child Welfare (cont.)

Level of Agreement Priority for 

Action

Recommendations/

Comments

Postnatal Period and After (cont.)

14. We understand and are 

equipped to facilitate access to 

the supports families need for 

long-term stability (e.g., ongoing 

medication-assisted treatment and 

other substance use treatment 

services, early intervention services 

for infants, home visiting services).

In the space provided under 

Recommendations/Comments, 

describe how care coordination 

is facilitated (e.g., by ongoing 

communication with treatment 

providers on the mother’s 

progress in recovery).

No To Some 

Extent Yes Not 

Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

15. We use a consistent protocol 

for making decisions on 

reunification and case closure.

In the space provided under 

Recommendations/Comments, 

describe how decisions are made 

(e.g., a shared understanding of 

what defines treatment success; 

how relapse is addressed).

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

16. For agencies that use a 

differential response program: 

Our agency has a system to 

ensure that families referred to 

community agencies to address 

opioid use disorders receive 

medication-assisted and other 

needed treatment services.

No To Some 

Extent Yes Not 

Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)
58

Appendix 1: Facilitator’s Guide, Guide 5: Child Welfare

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59

Appendix 1: Facilitator’s Guide, Guide 6: Dependency Court and Family Drug Court

Guide 6: Dependency Court and Family Drug Court

Introduction: The statements in this guide are to help establish a baseline understanding of the 

practices and policies within the dependency court system. The statements represent a policy or 

practice issue and are grouped into three time frames: pregnancy, birth, and postnatal/beyond. 

Having a baseline understanding of the practices and policies will help teams evaluate the strengths 

and challenges specific to dependency courts.

Who Should Complete This Guide? Dependency court professionals should complete this guide; 

these include judges, children’s attorneys, parents’ attorneys, and attorneys representing child welfare.

VI. Dependency Court and Family Drug Court

Level of Agreement Priority for 

Action

Recommendations/

Comments

Pregnancy 

1. We understand and are 

supportive of medicationassisted treatment as an 

evidence-based approach for 

pregnant women with opioid 

use disorders.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

2. We help facilitate access to 

medication-assisted treatment 

for pregnant women with opioid 

use disorders.

In the space provided under 

Recommendations/Comments, 

describe protocols, etc., that 

facilitate access (e.g., Safe Harbor 

laws).

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

3. We accept the clinical decisions 

that medical and substance 

use treatment professionals 

recommend on the treatment of 

opioid use disorders.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)
60

Appendix 1: Facilitator’s Guide, Guide 6: Dependency Court and Family Drug Court

VI. Dependency Court and Family Drug Court (cont.)

Level of Agreement Priority for 

Action

Recommendations/

Comments

Birth

4. We understand what information 

is needed from each service 

provider (i.e., substance use 

treatment, medication-assisted 

treatment, child welfare, and 

medical providers) to make 

decisions regarding child safety, 

placement, and permanency.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

5. We help ensure that 

care for infants is provided 

and coordinated.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

6. We have a role in shaping the 

plan of safe care, mandated by 

the Child Abuse Treatment and 

Prevention Act (CAPTA), for cases 

involving prenatal substance 

exposure.

In the space provided under 

Recommendations/Comments, 

describe how the plan of safe 

care is developed, what it 

typically entails, and whether 

its development involves a 

coordinated approach with child 

welfare and other service providers.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

7. We are familiar with best 

practices for mother–infant 

attachment (e.g., breastfeeding) 

for women receiving medicationassisted treatment.

No To Some 

Extent Yes Not 

Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)

Postnatal Period and After

8. For communities with a family 

treatment drug court (FTDC): 

The FTDC allows new mothers 

to receive medication-assisted 

treatment and remain eligible to 

participate in the program.

No To Some 

Extent Yes Not Sure

1 (Immediate)

2 (2 Years)

3 (3–5 Years)
61

Appendix 2: Citations

Appendix 2: Citations

American College of Obstetricians and Gynecologists Committee on Health Care for Underserved 

Women, & American Society of Addiction Medicine. (2012). Opioid abuse, dependence, and addiction 

in pregnancy. ACOG committee opinion no. 524. Obstetrics and Gynecology, 119(5), 1070–1076. 

Retrieved from http://www.acog.org/Resources-And-Publications/Committee-Opinions/

Committee-on-Health%20Care-for-Underserved-Women/Opioid-Abuse-Dependence-andAddiction-in-Pregnancy (accessed August 19, 2015).

American Society of Addiction Medicine. (2015). The national practice guideline for the use of 

medications in the treatment of addiction involving opioid use. Retrieved from http://www.asam.org/

quality-practice/guidelines-and-consensus-documents/npg (accessed August 19, 2015).

Behavioral Health Coordinating Committee. (2013). Addressing prescription drug abuse in the United 

States: Current activities and future opportunities. Washington, DC: Prescription Drug Abuse 

Subcommittee, U.S. Department of Health and Human Services. Retrieved from http://www.cdc.gov/

drugoverdose/pdf/hhs_prescription_drug_abuse_report_09.2013.pdf (accessed August 19, 2015).

Center for Substance Abuse Treatment. (2004). Clinical guidelines for the use of buprenorphine in 

the treatment of opioid addiction: Treatment Improvement Protocol (TIP) Series 40. HHS Publication 

No. (SMA) 04-3939. Rockville, MD: Substance Abuse and Mental Health Services Administration. 

Retrieved from http://buprenorphine.samhsa.gov/Bup_Guidelines.pdf (accessed August 19, 2015).

Center for Substance Abuse Treatment. (2005). Medication-assisted treatment for opioid addiction 

in opioid treatment programs: Treatment Improvement Protocol (TIP) Series 43. HHS Publication 

No. (SMA) 12-4214. Rockville, MD: Substance Abuse and Mental Health Services Administration. 

Retrieved from http://store.samhsa.gov/product/TIP-43-Medication-Assisted-Treatment-for-OpioidAddiction-in-Opioid-Treatment-Programs/SMA12-4214 (accessed August 19, 2015).

Centers for Disease Control and Prevention. (2011). Vital signs: Overdoses of prescription opioid pain 

relievers – United States, 1999–2008. Morbidity and Mortality Weekly Report, 60(43), 1487–1492. 

Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm (accessed August 

19, 2015).

Centers for Disease Control and Prevention. (2013). Vital signs: Overdoses of prescription opioid pain 

relievers and other drugs among women – United States, 1999–2010. Morbidity and Mortality Weekly 

Report, Vol. 62, No. 26. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6226a3.

htm (accessed August 19, 2015).

Child Abuse Prevention and Treatment Reauthorization Act of 2010. 42 U.S.C. 5101 et seq.; 42 

U.S.C. 5116 et seq. Retrieved from http://www.gpo.gov/fdsys/pkg/BILLS-111s3817enr/pdf/BILLS111s3817enr.pdf (accessed August 19, 2015).

Compton, W.M., Jones, C.M. & Baldwin, G.T. (2016). Relationship between non-medical prescriptionopioid use and heroin use. New England Journal of Medicine, 374(2), 154-163.

Farid, W. O., Dunlop, S. A., Tait, R. J., & Hulse, G. K. (2008). The effects of maternally administered 

methadone, buprenorphine and naltrexone on offspring: Review of human and animal data. 

Current Neuropharmacology, 6(2), 125–150. Retrieved from http://www.ncbi.nlm.nih.gov/

pubmed/19305793 (accessed August 19, 2015).
62

Appendix 2: Citations

Fingar, K.R., Stocks, C., Weiss, A.J., & Owens, P.L. (2015). Neonatal and maternal hospital stays related to 

substance use, 2006–2012. HCUP Statistical Brief #193. Agency for Healthcare Research and Quality, 

Rockville, MD. Retrieved from http://hcup-us.ahrq.gov/reports/statbriefs/sb193-Neonatal-MaternalHospitalizations-Substance-Use.pdf (accessed July 13, 2016).

Finnegan, L. P. (1991). Treatment issues for opioid-dependent women during the perinatal period. Journal 

of Psychoactive Drugs, 23(2), 191–201. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/?term

=Treatment+issues+for+opioid-dependent+women+during+the+perinatal+period.+Journal+of+P

sychoactive+Drugs (accessed August 19, 2015).

Fischer, G., Ortner, R., Rohmeister, K., Jagsch, R., Baewert, A., Langer, M., & Aschauer, H. (2006).

Methadone versus buprenorphine in pregnant addicts: A double-blind, double-dummy comparison

study. Addiction, 101, 275–281. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/j.1360-

0443.2006.01321.x/abstract?systemMessage=Wiley+Online+Library+will+be+

disruped+on+the+18th+October+from+10%3A00+BST+%2805%3A00+EDT%29+for+essential+

maintenance+for+approximately+tw+hours+as+we+make+upgrades+to+improve+our+services+

to+you (accessed August 19, 2015).

Guttmacher Institute. (2015). State policies in brief: Substance abuse during pregnancy. New York and 

Washington, DC: Guttmacher Institute. Retrieved from http://www.guttmacher.org/statecenter/

spibs/spib_SADP.pdf (accessed August 19, 2015).

Hamilton, R., McGlone, L., MacKinnon, J. R., Russell, H. D., Bradnam, M. S., & Mactier, H. (2010). 

Ophthalmic, clinical and visual electrophysiological findings in children born to mothers prescribed 

substitute methadone in pregnancy. British Journal of Ophthalmology, 6, 696–700. Retrieved from 

http://www.ncbi.nlm.nih.gov/pubmed/20410537 (accessed August 19, 2015).

Hedegaard H., Chen, L. H., & Warner, M. (2015). Drug-poisoning deaths involving heroin: United States, 

2000–2013. NCHS Data Brief, 190. Hyattsville, MD: National Center for Health Statistics, Centers for 

Disease Control and Prevention. Retrieved from http://www.cdc.gov/nchs/data/databriefs/db190.

pdf (accessed August 19, 2015).

Hudak, M. L., & Tan, R. C. (2012). Neonatal drug withdrawal. Pediatrics, 129(2), e540–e560. Retrieved 

from http://pediatrics.aappublications.org/content/129/2/e540.abstract (accessed August 19, 

2015).

International Drug Policy Consortium. (2013). Open letter regarding alarmist and inaccurate reporting 

on prescription opiate use by pregnant women. London: International Doctors for Healthy Drug 

Policies. Retrieved from http://idpc.net/alerts/2013/03/open-letter-regarding-alarmist-andinaccurate-reporting-on-prescription-opiate-use-by-pregnant-women (accessed August 19, 2015).

Jansson, L. M., Velez, M., & Harrow, C. (2009). The opioid exposed newborn: Assessment and 

pharmacological management. Journal of Opioid Management, 5(1), 47–55. 

Jones, H. E., Johnson, R. E., Jasinski, R., O’Grady, K. E., Chisholm, C. A., Choo, R. E., & Milio, L. (2005). 

Buprenorphine versus methadone in the treatment of pregnant opioid-dependent patients: Effects on 

the neonatal abstinence syndrome. Drug and Alcohol Dependence, 79, 1–10. Retrieved from http://

www.ncbi.nlm.nih.gov/pubmed/15943939 (accessed August 19, 2015).

Jones, H. E., O’Grady, K. E., Malfi, D., & Tuten, M. (2008). Methadone maintenance vs. methadone taper 

during pregnancy: Maternal and neonatal outcomes. American Journal of Addictions, 17, 372–386.
63

Appendix 2: Citations

Jones, H. E., Kaltenbach, K., Heil, S., Stine, S. M., Coyle, M. G., Arria, A. M., O’Grady, K., Selby, P., Martin, 

P., & Fischer, G. (2010). Neonatal abstinence syndrome after methadone or buprenorphine exposure. 

New England Journal of Medicine, 363, 2320–2331. Retrieved from http://www.nejm.org/doi/

full/10.1056/NEJMoa1005359 (accessed August 19, 2015).

Jones, H. E., Chisolm, M. S., Jansson L. M., & Terplan M. (2013). Naltrexone in the treatment of opioiddependent pregnant women: Common ground. Addiction, 108(2), 255–256.

Kaltenbach, K., Berghella, V., & Finnegan, L. (1998). Opioid dependence during pregnancy: Effects and 

management. Obstetrics and Gynecology Clinics of North America, 25(1), 139–151.

Kaltenbach, K., & Finnegan, L. (1998). Prevention and treatment issues for pregnant cocaine-dependent 

women and their infants. Annals of the New York Academy of Sciences, 846, 329–334. Retrieved from 

http://www.ncbi.nlm.nih.gov/pubmed/9668419 (accessed August 19, 2015).

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pregnancy. Clinics in Perinatology, 26(1), 173–183. Retrieved from http://www.ncbi.nlm.nih.gov/

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adoption opportunities & the abandoned infants assistance act. Washington, DC: Children’s Bureau. 

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Patrick, S. W., Schumacher, R. E., Benneyworth, B. D., Krans, E. E., McAllister, J. M., & Davis, M. M. (2012). 

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addicted mothers given opiate maintenance treatment with buprenorphine during pregnancy. Acta 

Pediatrica, 102(5), 544–549.

Werner, D., Young, N. K., Dennis, K., & Amatetti, S. (2007). Family-centered treatment for women with 

substance use disorders: History, key elements and challenges. Retrieved from http://www.samhsa.

gov/sites/default/files/family_treatment_paper508v.pdf (accessed August 19, 2015).

Whitten, L. (2012). Buprenorphine during pregnancy reduces neonate distress. Retrieved from http://

www.drugabuse.gov/news-events/nida-notes/2012/07/buprenorphine-during-pregnancyreduces-neonate-distress (accessed August 19, 2015).

World Health Organization. (2014). Guidelines for identification and management of substance use and 

substance use disorders in pregnancy. Geneva: World Health Organization. Retrieved from http://

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Young, N. K., Gardner, S., Otero, C., Dennis, K., Chang, R., Earle, K., & Amatetti, S. (2009). Substanceexposed infants: State responses to the problem. HHS Pub. No. (SMA) 09-4369. Rockville, MD: 

Substance Abuse and Mental Health Services Administration. Retrieved from http://store.samhsa.

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Young, N. K., Nakashian, M., Yeh, S., & Amatetti, S. (2006). Screening and Assessment for Family 

Engagement, Retention and Recovery (SAFERR). HHS Pub. No. (SMA) 06-0000. Rockville, MD: 

Substance Abuse and Mental Health Services Administration. Retrieved from http://store.samhsa.

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Appendix 3: Training Needs

Appendix 3: Training Needs and Resources

Training Needs

The national work group of experts that developed the recommendations in this report identified 

common barriers and strategies to improve system linkages to serve pregnant and parenting 

women with opioid use disorders more effectively. Through this effort, the group identified the 

following training needs:

§ Medication-Assisted Treatment (MAT): evidence-based care and use of MAT (including for

MAT providers), use and efficacy of MAT during pregnancy, and complications of MAT with other

prescriptions (i.e., opioid pain medications)

§ Substance Use, Misuse, and Addiction: addiction, substance abuse treatment, recovery and

opioids, what family-centered treatment means and includes, trauma-informed treatment

(including trauma associated with loss of child custody), recovery definitions and practices, and

characteristics of gender-responsive treatment

§ Role of Child Welfare Agencies: role of child welfare agencies and policies regarding removal of

infants from parents and visitation for children in out-of-home care

§ Screening and Assessment: best practices for toxicology screening of both women and infants

in medical settings, how to interpret drug screen results, brief screening interviews to differentiate

between active and well-controlled substance use disorder, understanding sudden infant death

syndrome risks and preventative efforts, screening and monitoring for newborns, interventions for

neonatal abstinence syndrome (NAS), and assessments of developmental needs in newborns and

infants

§ System Linkages and Information Sharing: how, when, and where to refer women for

treatment and other services and which women to transfer; how and where to refer children for

developmental services; and how to gather more information from medical providers

§ Pregnancy and Family Planning: asking about pregnancy in non-medical settings and effective

family planning counseling in medical settings as a general standard for all patients, including

during pregnancy and after delivery

Federal, National, and International Guidelines

Numerous resources are available to help states, local agencies and organizations, and providers 

establish policies, guidelines, and protocols to support pregnant women with opioid use disorders, 

their newborns, and other family members. The following resources provide information for health 

care, substance use treatment, child welfare, and dependency court professionals.

§ Academy of Breastfeeding Medicine. Reece-Stremtan, S. & Marinelli, K. A. (2015). ABM Clinical

Protocol #21: Guidelines for breastfeeding and substance use or substance use disorder, revised 2015.

Breastfeeding Medicine, 10(3) 135–141. This literature based protocol serves as guidelines for

the care of breastfeeding mothers and their infants. The protocol does not delineate an exclusive

course of treatment or serve as standards of medical care. Retrieved from http://www.bfmed.

org/Media/Files/Protocols/Guidelines%20for%20Breastfeeding%20and%20Substance%20

Use%20or%20Use%20Disorder.pdf (accessed January 20, 2016).

§ American Academy of Pediatrics. Hudak, M. L., & Tan, R. C. (2012). Neonatal drug withdrawal.

Pediatrics, 129(2), e540–e560. Retrieved from http://pediatrics.aappublications.org/

content/129/2/e540 (accessed August 19, 2015). These guidelines and policy recommendations
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are designed for hospitals, pediatricians, and neonatologists providing care for opioid-exposed 

infants at risk of NAS.

§ American Psychiatric Association. Kleber, H. D., Weiss, R. D., Anton, R. F. Jr., George, T. P.,

Greenfield, S. F., Kosten, T. R., & Connery, H. S. (2006). Practice guideline for the treatment of

patients with substance use disorders (2nd ed.). Arlington, VA: American Psychiatric Association.

Retrieved from http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/

guidelines/substanceuse.pdf (accessed August 19, 2015). These guidelines offer treatment

recommendations and tools for creating individualized treatment plans based on patient needs.

§ American Society for Pain Management Nursing. Oliver, J., Coggins, C., Compton, P., Hagan, S.,

Matteliano, D., Stanton, M., & Turner, H. N. (2012). American Society for Pain Management Nursing

position statement: Pain management in patients with substance use disorders. Pain Management

Nursing, 13(3), 169–183. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3741053

(accessed August 19, 2015). This position statement, endorsed by the International Nurses

Society on Addictions, includes clinical practice recommendations based on current evidence.

The authors state that all patients with pain, including those with substance use disorders, have

the right to be treated with dignity, respect, and high-quality pain assessment and management.

§ American Society of Addiction Medicine. American Society of Addiction Medicine. (2015).

National Practice Guideline for Medications for the Treatment of Opioid Use Disorder. Chevy Chase,

MD: American Society of Addiction Medicine. Retrieved from http://www.asam.org/qualitypractice/guidelines-and-consensus-documents/npg (accessed August 19, 2015). This guideline

aids in clinical decision making and patient management in the treatment of opioid use

disorders. Included are recommendations for assessment, diagnosis, and treatment.

§ American Society of Addiction Medicine. American Society of Addiction Medicine. (2013).

Advancing access to addiction medications: Implications for opioid addiction treatment. Chevy

Chase, MD: American Society of Addiction Medicine. Retrieved from http://www.asam.org/docs/

default-source/advocacy/aaam_implications-for-opioid-addiction-treatment_final.pdf?sfvrsn=25

(accessed August 19, 2015). This systematic review of empirical research focuses on the

effectiveness of pharmacotherapies (e.g., methadone, buprenorphine, buprenorphine plus

naloxone, naltrexone, and extended-release naltrexone) in the treatment of opioid use disorders.

§ Association of State and Territorial Health Officials. Association of State and Territorial Health

Officials. (2014). Neonatal abstinence syndrome: How states can help advance the knowledge

base for primary prevention and best practices of care. Retrieved from http://www.astho.org/

Prevention/NAS-Neonatal-Abstinence-Report (accessed August 19, 2015). This document

describes a state-level approach to addressing NAS and includes examples of what states have

implemented to address the issue.

§ World Health Organization. World Health Organization. (2014). Guidelines for

the identification and management of substance use and substance use disorders in

pregnancy. Geneva: World Health Organization. Retrieved from http://apps.who.int/iris/

bitstream/10665/107130/1/9789241548731_eng.pdf?ua=1 (accessed August 19, 2015). These

guidelines contain recommendations for health care providers on the identification and care

management of women who are pregnant or have recently had a child and who use alcohol or

drugs or have a substance use disorder to ensure healthy outcomes for pregnant women and

their infants.

§ Substance Abuse and Mental Health Services Administration, Center for Substance Abuse

Treatment, Division of Pharmacologic Therapies (DPT). Retrieved from http://www.samhsa.

gov/medication-assisted-treatment/about (accessed August 19, 2015). DPT manages the dayto-day regulatory oversight activities on the use of opioid agonist medications (methadone and
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Appendix 3: Training Needs

buprenorphine). These activities include supporting the certification and accreditation of more 

than 1,250 opioid treatment programs. DPT also implements the Drug Addiction Treatment Act 

of 2000 (DATA 2000), which expands the clinical context of medication-assisted opioid addiction 

treatment by allowing qualified physicians to dispense or prescribe approved medications for the 

treatment of opioid use disorders in treatment settings other than the traditional opioid treatment 

program. DPT supports the training of medical and substance abuse professionals on a variety of 

treatment issues, including on medication-assisted treatment for opioid use disorders. 

§ Center for Substance Abuse Treatment. Center for Substance Abuse Treatment. (2004).

Clinical guidelines for the use of buprenorphine in the treatment of opioid addiction. A Treatment

Improvement Protocol (TIP) Series 40. HHS Publication No. (SMA) 04-3939. Rockville,

MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://

store.samhsa.gov/product/TIP-40-Clinical-Guidelines-for-the-Use-of-Buprenorphine-in-theTreatment-of-Opioid-Addiction/SMA07-3939 (accessed August 19, 2015). These practice

guidelines are designed to help physicians make decisions about using buprenorphine to treat

opioid use disorders. The document includes information on patient assessment; protocols for

opioid withdrawal; and the treatment of pregnant women, teens, and polysubstance users.

§ Center for Substance Abuse Treatment. Center for Substance Abuse Treatment. (2010). Drugtesting in child welfare: Practice and policy considerations. HHS Pub. No. (SMA) 10-4556. Rockville,

MD: Substance Abuse and Mental Health Services Administration. Retrieved from https://www.

ncsacw.samhsa.gov/files/DrugTestinginChildWelfare.pdf (accessed August 19, 2015). This guide

helps child welfare policy makers develop practice and policy protocols regarding drug testing in

child welfare practice. This guidance describes issues that policy makers must address to include

drug testing in the comprehensive assessment and monitoring that child welfare agencies provide.

§ Center for Substance Abuse Treatment. Center for Substance Abuse Treatment. (2005).

Medication-assisted treatment for opioid addiction in opioid treatment programs. A Treatment

Improvement Protocol (TIP) Series 43. HHS Publication No. (SMA) 05-4048. Rockville, MD:

Substance Abuse and Mental Health Services Administration. Retrieved from http://store.

samhsa.gov/product/TIP-43-Medication-Assisted-Treatment-for-Opioid-Addiction-in-OpioidTreatment-Programs/SMA12-4214 (accessed August 19, 2015). TIP 43 offers a detailed

description of medication-assisted treatment for opioid use disorders, including comprehensive

maintenance treatment, detoxification, and medically supervised withdrawal. It also discusses

screening, assessment, and administrative and ethical issues.

§ Substance Abuse and Mental Health Services Administration. Substance Abuse and Mental

Health Services Administration. (2011). Managing chronic pain in adults with or in recovery from

substance use disorders. A Treatment Improvement Protocol (TIP) Series 54. HHS Publication

No. (SMA) 12-4671. Rockville, MD: Substance Abuse and Mental Health Services Administration.

Retrieved from http://store.samhsa.gov/shin/content/SMA12-4671/TIP54.pdf (accessed August

19, 2015). TIP 54 gives clinicians practical guidance and tools for treating chronic pain in adults

with a history of substance use. The document also discusses chronic pain management,

including treatment with opioids, and offers information about substance use disorder

assessments and referrals.

§ Substance Abuse and Mental Health Services Administration. Substance Abuse and Mental

Health Services Administration. (2009). Substance abuse treatment: Addressing the specific needs

of women. A Treatment Improvement Protocol (TIP) Series 51. HHS Publication No. (SMA) 14-

4426. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved

from http://store.samhsa.gov/shin/content/SMA14-4426/SMA14-4426.pdf (accessed August

19, 2015). Tip 51 helps providers offer treatment to women with substance use disorders and

reviews gender-specific research and best practices, such as common patterns of initiation of

substance use among women and treatment issues and strategies.
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Appendix 3: Training Needs

§ Substance Abuse and Mental Health Services Administration. Werner, D., Young, N. K., 

Dennis, K., & Amatetti, S. (2007). Family-centered treatment for women with substance use 

disorders: History, key elements, and challenges. Rockville, MD: Substance Abuse and Mental 

Health Services Administration. Retrieved from http://samhsa.gov/sites/default/files/family_

treatment_paper508v.pdf (accessed August 19, 2015). This guide describes the effects of familycentered treatment on treatment retention and other outcomes in women, children, and other 

family members.

§ Substance Abuse and Mental Health Services Administration. Young, N. K., Nakashian, M., 

Yeh, S., & Amatetti, S. (2006). Screening and assessment for family engagement, retention, and 

recovery (SAFERR). Rockville, MD: Substance Abuse and Mental Health Services Administration. 

Retrieved from https://www.ncsacw.samhsa.gov/files/SAFERR.pdf (accessed August 19, 2015). 

SAFERR is a collaborative model to help child welfare, substance use disorder treatment, and 

family court professionals make informed decisions when determining outcomes for children 

and families affected by substance use disorders. This guide provides strategies to help improve 

collaborative capacities across systems.

§ Substance Abuse and Mental Health Services Administration. Young, N. K., Gardner, S., 

Otero, C., Dennis, K., Chang, R., Earle, K., & Amatetti, S. (2009). Substance-exposed infants: State 

responses to the problem. HHS Pub. No. (SMA) 09‐4369. Rockville, MD: Substance Abuse and 

Mental Health Services Administration. Retrieved from https://www.ncsacw.samhsa.gov/files/

Substance-Exposed-Infants.pdf (accessed August 19, 2015). This report provides an in‐depth 

review of state legislation and regulations, interagency agreements, and budget allocations 

related to substance-exposed infants; documents policies in 10 states that address one or more 

of five intervention points; and summarizes national research on other state policies focused on 

substance-exposed infants.

State Guidelines

§ Maine: Division of Population Health. (2013). Children with special health needs. Retrieved 

from http://www.maine.gov/dhhs/mecdc/population-health/mch/cshn/ (accessed August 19, 

2015). Maine’s Snuggle ME project includes tools and practice guidelines for obstetricians and 

pediatricians caring for pregnant women and their newborns to screen and treat pregnant women 

with substance use disorders for alcohol or other prescribed or nonprescribed substances, such as 

methadone, buprenorphine, and oxycodone.

§ Vermont: Vermont Department of Health, Division of Alcohol and Substance Abuse Programs, & 

Department of Vermont Health Access. Vermont guidelines for medication assisted treatment (MAT) 

for pregnant women. (n.d.). Retrieved from http://www.uvm.edu/medicine/vchip/documents/

VCHIP_4MAT_GUIDELINES.pdf (accessed August 19, 2015). This guidance provides a consolidated 

set of recommendations for managing opioid use disorders during pregnancy. 

§ Washington: Washington State Department of Health. (2012). Substance abuse during pregnancy: 

Guidelines for screening. Olympia, WA: Washington State Department of Health. Retrieved from 

http://aia.berkeley.edu/media/pdf/WA_15_PregSubs_E12L.pdf (accessed August 19, 2015). This 

best-practice guide on screening pregnant women for substance use and misuse is for health care 

professionals; the document also provides information and resources on treatment. 
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Appendix 3: Training Needs

Webinars and Conference Presentations

§ Children and Family Futures. (2014). Medication assisted treatment during pregnancy, postnatal 

and beyond. Retrieved from http://www.cffutures.org/presentations/webinars/medicationassisted-treatment-during-pregnancy-postnatal-and-beyond (accessed August 19, 2015). This 

presentation describes the use of MAT to treat opioid use disorders in pregnant women and the 

effects of this use on relationships among treatment providers, dependency courts, and child 

welfare agencies.

§ Young, N. K. (2013). Medication assisted treatment (MAT): A component of comprehensive 

treatment for substance use disorders. Retrieved from http://www.cffutures.org/files/

presentations/TN%20MAT-NAS%207-2013.pdf (accessed August 19, 2015). This presentation 

addresses the brain science around addiction and the use of MAT as part of an evidence-based, 

holistic treatment approach, with a focus on MAT during pregnancy, after birth, and beyond.

§ Fields, J., Mann, L., & DeCerchio, K. (2012). Understanding medication-assisted treatment for 

families affected by parental substance use disorders. Presentation at 18th National Conference on 

Child Abuse & Neglect, Washington, DC, April 16–20, 2012. Retrieved from http://www.cffutures.

org/files/conference2011/sessions/A11/PPT-Understanding_MAT_for_Families.pdf (accessed 

August 19, 2015). This presentation describes the epidemic rise in prescription drug use and 

misuse and the need for persons working with children and families to understand the efficacy, 

use, and implications of MAT for families receiving child welfare services.

§ Gardner, S., Chasnoff, I., Green, S., & Kurgans, M. (2012). Identifying and responding to the 

needs of substance-exposed infants and their families—It takes a collaborative. Presentation at 18th 

National Conference on Child Abuse & Neglect, Washington, DC, April 16–20, 2012. Retrieved 

from http://www.cffutures.com/files/presentations/SEI_OCAN_Final.pdf (accessed August 19, 

2015). This presentation highlights effective programmatic responses to the needs of children 

and families by describing the prevalence and impact of prenatal exposure on children and 

families, practice and policy implications, strategies for building and expanding collaborative 

efforts to address the needs of this population, and examples of successful national and 

statewide programs.

§ Breitenbucher, P., Panzarella, P., & Moy, S. (2012). Drug testing: Managing resources 

for better outcomes. Retrieved from http://www.cffutures.org/files/presentations/

DrugTestingManagingResourcesForBetterOutcomesOCAN.pdf (accessed August 19, 2015). 

This presentation provides insight into why drug testing is important in child welfare and key 

considerations for developing a drug-testing policy.

§ Clodfelter, P., Haskins, K., & Young, N. K. (2014). Closed doors or welcome mat? Opening the 

way for medical assisted treatment in FDC. Retrieved from http://www.cffutures.org/presentations/

webinars/closed-doors-or-welcome-mat-opening-way-medical-assisted-treatment-fdc (accessed 

August 19, 2015). This webinar presentation from the Office of Juvenile Justice and Delinquency 

Prevention’s Office of Justice Programs provides an overview of MAT and key considerations for 

opening doors for this population as well as practice and policy examples and implications for 

collaborative practice between child welfare agencies, treatment programs, and courts. 

§ National Abandoned Infants Assistance Resource Center. (2009). Collaborative approaches 

to identifying and serving substance exposed newborns: Lessons learned from four demonstration 

projects. Retrieved from http://aia.berkeley.edu/training/online/webcasts/sen (accessed August 

19, 2015). Representatives from four federally funded demonstration projects share their 

experiences in developing policies and procedures to comply with the federal Child Abuse 
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Appendix 3: Training Needs

Prevention and Treatment Act mandates related to infants affected by illegal substance use or 

withdrawal symptoms resulting from prenatal exposure or a fetal alcohol spectrum disorder. The 

presenters discuss their challenges in multidisciplinary collaboration and the strategies they used 

to overcome those challenges.

§ The Providers’ Clinical Support System for Opioid Therapies (PCSS-O). The PCSS-O is 

a consortium of professional health care organizations, including the American Medical 

Association, American Academy of Addiction Psychiatry, American Psychiatric Association, and 

International Nurses Society on Addictions. The consortium offers trainings on the safe and 

effective use of opioid medications. Selected presentations include and can be accessed from 

http://pcss-o.org/ (accessed August 19, 2015).

§ Treating Women for Opioid Dependence During Pregnancy and the Postpartum Period: The 

Importance of Science and Clinical Care Informing Each Other. Discusses the benefits and 

risks of providing methadone, buprenorphine, or medication-assisted withdrawal during 

pregnancy for the mother, fetus, and newborn. Examines different approaches for addressing 

opioid use disorders during pregnancy and the postpartum period.

§ Parenting and Concerns of Pregnant Women in Buprenorphine Treatment. Discusses emerging 

trends in prescription drug use and misuse, maternal opioid use, NAS, parenting, and 

child welfare. Discusses discrepancies between parenting concerns and parenting skills of 

pregnant women with opioid use disorders, the development of an integrated model of 

behavioral and medical treatment, and policy recommendations.

§ Buprenorphine Clinic: A Multidisciplinary Model for Opioid Maintenance Therapy. Reviews 

introductory and background information on the design, implementation, and evaluation of 

a multidisciplinary outpatient buprenorphine clinic for opioid maintenance therapy.

§ Assessment of Patients with Chronic Pain and Co-Occurring Substance Use. Addresses the types 

of screening used to determine an appropriate assessment for pain and addiction to aid 

physicians in determining whether long-term opioid medications are a viable option for a 

patient with chronic pain. 

§ Treating Chronic Pain with Prescription Opioids in the Person with Substance Use Disorders: 

Relapse Prevention & Management. Provides a comprehensive understanding of treating 

chronic pain with prescription opioids in the person with substance use disorders. 

Online Tutorials

National Center on Substance Abuse and Child Welfare, Substance Abuse and Mental Health 

Services Administration, (2007).

§ Tutorial 1: Understanding child welfare and the dependency court: A guide for substance abuse 

treatment professionals. Retrieved from https://www.ncsacw.samhsa.gov/tutorials/tutorialDesc.

aspx?id=26 (accessed November 6, 2015). This tutorial provides comprehensive information 

regarding child welfare issues for substance abuse treatment professionals.

§ Tutorial 2: Understanding substance use disorders, treatment and family recovery: A guide for child 

welfare professionals. Retrieved from https://www.ncsacw.samhsa.gov/tutorials/tutorialDesc.

aspx?id=27 (accessed November 6, 2015). This primer addresses addiction, substance abuse 

treatment and recovery, treatment readiness and treatment effectiveness, cross-system 

communication and collaboration, and contact information for other national resources.
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Appendix 3: Training Needs

§ Tutorial 3: Understanding substance use disorders, treatment, and family recovery: A guide for legal

professionals. Retrieved from https://www.ncsacw.samhsa.gov/tutorials/tutorialDesc.aspx?id=28

(accessed November 6, 2015). This primer addresses addiction, treatment and recovery, the

impact of substance abuse on children and families, child welfare timetables and their impact

on parenting, cross-system communication and collaboration, and contact information for other

national resources.

Brochures for Parents and Other Consumers

§ Nurse Family Partnership. Caring for babies who have been exposed to drugs or alcohol.

Retrieved from http://www.cffutures.org/files/publications/SEI%20Brochure_Final.pdf (accessed

August 19, 2015). This brochure is designed for parents and caregivers of infants with prenatal

substance exposure. It offers caregiving tips for soothing a baby as well as resources in the

Sacramento, California, region. Those interested in personalizing this brochure in a given region

should send an e-mail to ncsacw@cffutures.org to request a customizable version.

Resource Locators

§ Substance Abuse and Mental Health Services Administration. Buprenorphine physician and

treatment program locator. Retrieved from http://dpt2.samhsa.gov/treatment/directory.aspx

(accessed August 19, 2015). This directory enables providers to locate physician(s) and treatment

program(s) authorized to treat opioid addiction with buprenorphine in a particular state. This

site also has a link to a page for pharmacists to verify whether a prescribing physician has a valid

Drug Addiction Treatment Act (DATA) of 2000 waiver.

§ National Alliance of Advocates for Buprenorphine Treatment. Treatment match. Retrieved

from http://www.treatmentmatch.org/index.cfm (accessed August 19, 2015). This anonymous,

free, and confidential service connects people seeking treatment for addiction with treatment

providers.

§ Substance Abuse and Mental Health Services Administration. Opioid treatment program

directory. Retrieved from http://dpt2.samhsa.gov/treatment/directory.aspx (accessed August 19,

2015). This online directory allows providers to search for treatment programs by state.

Organization Websites and Reports

§ American Association for the Treatment of Opioid Dependence. http://www.aatod.org. This

association enhances the quality of patient care in treatment programs by promoting the growth

and development of comprehensive opioid treatment services throughout the United States.

§ Legal Action Center. http://lac.org/. Legal Action Center is the only nonprofit law and policy

organization in the United States whose sole mission is to fight discrimination against people

with histories of addiction, HIV/AIDS, or criminal records and to advocate for sound public

policies in these areas. Legal Action Center has published the following reports:

– Legal Action Center. (2011). Legality of denying access to medication assisted treatment in the

criminal justice system. New York and Washington, DC: Legal Action Center. Retrieved from

http://www.lac.org/doc_library/lac/publications/MAT_Report_FINAL_12-1-2011.pdf (accessed

August 19, 2015). This report analyzes the circumstances in which the denial of MAT violates

federal antidiscrimination laws and the U.S. Constitution.
74

Appendix 3: Training Needs

– Legal Action Center. (2010). Confidentiality of alcohol and drug records in the 21st century. 

New York and Washington, DC: Legal Action Center. Retrieved from http://lac.org/wpcontent/uploads/2014/12/Confidentiality_of_Alcohol_and_Drug_Records_in_the_21st_

Century-1-20-10.pdf (accessed August 19, 2015). This report discusses effective ways to 

increase communication between providers of alcohol and drug treatment and recovery 

services and other health care professionals while maintaining patient privacy.

For additional resources, contact the National Center on Substance Abuse and Child Welfare: 

Phone: 1-866-493-2758; website: www.ncsacw.samhsa.gov; e-mail: ncsacw@cffutures.org
75

Appendix 4: Key Features of Medications Approved for Treating Opioid Use Disorders

Appendix 4: Key Features of Medications Approved 

for Treating Opioid Use Disorders1,2 

Prescribing 

Considerations

Extended-Release 

Injectable Naltrexone3 Methadone4 Buprenorphine5

Frequency of 

Administration

Monthly6 Daily Daily (also alternative 

dosing regimens)

Route of 

Administration

Intramuscular (IM) 

injection into the 

gluteal muscle 

by a physician or 

other health care 

professional.6 

Orally as liquid 

concentrate, 

tablet, or oral 

solution of 

diskette or 

powder.

Oral tablet or film 

is dissolved under 

the tongue.

Who May Prescribe 

or Dispense

Any individual who is 

licensed to prescribe 

medicines (e.g., 

physician, physician 

assistant, nurse 

practitioner) may 

prescribe and/or order 

administration by 

qualified staff.

SAMHSA-certified 

OTPs dispense 

methadone 

for daily 

administration 

either on site or, 

for stable patients, 

at home.

Physicians must have board 

certification in addiction 

medicine or addiction 

psychiatry and/or complete 

special training to qualify 

for the federal waiver to 

prescribe buprenorphine, 

but any pharmacy can fill 

the prescription. 

There are no special 

requirements for staff 

members who dispense 

buprenorphine under the 

supervision of a waivered 

physician.

1

 Substance Abuse and Mental Health Services Administration. (2014). Table 1 is reproduced with modifications from: 

Clinical Use of Extended-Release Injectable Naltrexone in the Treatment of Opioid Use Disorder: A Brief Guide. HHS 

Publication No. (SMA) 14-4892R. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved 

from http://store.samhsa.gov/shin/content//SMA14-4892R/SMA14-4892R.pdf (accessed August 19, 2015). See source 

document for references. 

2

 The table highlights some properties of each medication. It does not provide complete information and is not intended 

as a substitute for the package inserts or other drug reference sources used by clinicians (see http://www.dailymed.nlm.nih.

gov for current package inserts). For patient information about these and other drugs, visit the National Library of Medicine’s 

MedlinePlus (http://www.medlineplus.gov). Whether a medication should be prescribed and in what amount are matters to 

be discussed between an individual and his or her health care provider. The prescribing information provided here is not a 

substitute for the clinician’s judgment, and the National Institutes of Health and SAMHSA accept no liability or responsibility for 

the use of the information in the care of individual patients.

3

 The brand name for naltrexone is Vivitrol®.

4

 The brand names for methadone are Dolophine® and MethadoseTM.

5

 The brand names for the combination medication buprenorphine/naloxone is Suboxone® and Zubsolv®.

6

 Naltrexone hydrochloride tablets (50 mg each) are also available for daily dosing.
76

Appendix 4: Key Features of Medications Approved for Treating Opioid Use Disorders

Prescribing 

Considerations

Extended-Release 

Injectable Naltrexone3 Methadone4 Buprenorphine5

Pharmacologic 

Category

Opioid antagonist7 Opioid agonist Opioid partial agonist

Buprenorphine’s partial 

agonist effect relieves 

withdrawal symptoms 

resulting from cessation of 

opioids. This same property 

will induce a syndrome 

of acute withdrawal in 

the presence of longacting opioids or sufficient 

amounts of receptor-bound 

full agonists. Naloxone, 

an opioid antagonist, 

is sometimes added to 

buprenorphine to make 

the product less likely to be 

abused by injection.

7

 Opioid agonists bind to brain receptors, producing feelings of euphoria, sedation, and pain relief. When used to treat opioid 

use disorders, agonists occupy brain receptors to block the effects of other opioids. Partial opioid agonists bind to brain 

receptors without completely stimulating them, producing a “ceiling effect” so that taking more of the mediation does not 

increase euphoria or sedation. Opioid antagonists bind to brain receptors and block or sometimes reverse the effects of 

opioids (e.g., feelings of euphoria). For more information, see http://store.samhsa.gov/product/TIP-43-Medication-AssistedTreatment-for-Opioid-Addiction-in-Opioid-Treatment-Programs/SMA12-4214.
77

Appendix 4: Key Features of Medications Approved for Treating Opioid Use Disorders

Prescribing 

Considerations

Extended-Release 

Injectable Naltrexone3 Methadone4 Buprenorphine5

Clinical Uses/Ideal 

Candidates

Prevention of relapse 

to opioid use disorders 

following opioid 

detoxification; studies 

suggest benefits 

for patients who 

are experiencing 

increased stress or 

other relapse risks 

(e.g., visiting places of 

previous drug use, loss 

of spouse, loss of job).

Appropriate for 

patients who have 

been detoxified from 

opioids and who are 

being treated for a 

co-occurring alcohol 

use disorder.

Extended-release 

naltrexone should 

be part of a 

comprehensive 

management 

program that includes 

psychosocial support.

Other good 

candidates include 

persons with a short or 

less severe addiction 

history or who must 

demonstrate to 

professional licensing 

boards or criminal 

justice officials that 

their risk of opioid use 

is low.

Detoxification 

and maintenance 

treatment of 

opioid use 

disorders.

Patients who 

are motivated 

to adhere to the 

treatment plan 

and who have no 

contraindications 

to methadone 

therapy.

Methadone 

should be part of 

a comprehensive 

management 

program 

that includes 

psychosocial 

support.

Treatment of 

opioid use disorders.

Patients who are motivated 

to adhere to the treatment 

plan and who have no 

contraindications to 

buprenorphine therapy.

Buprenorphine should 

be part of a comprehensive 

management program 

that includes 

psychosocial support.
78

Appendix 4: Key Features of Medications Approved for Treating Opioid Use Disorders

Prescribing 

Considerations

Extended-Release 

Injectable Naltrexone3 Methadone4 Buprenorphine5

Contraindications Contraindicated in 

patients receiving longterm opioid therapy. 

Contraindicated in 

patients who are 

engaged in current 

opioid use (as indicated 

by self-report or a 

positive urine drug 

screen) or who are 

on buprenorphine or 

methadone maintenance 

therapy, as well as 

in those currently 

undergoing opioid 

withdrawal. 

Contraindicated 

in patients with a 

history of sensitivity to 

polylactide-co-glycolide, 

carboxymethylcellulose, 

or any components of 

the diluent.

Should not be given 

to patients whose 

body mass precludes 

IM injection with 

the 2-inch needle 

provided; inadvertent 

subcutaneous injection 

may cause a severe 

injection site reaction. 

Should not be 

given to anyone allergic 

to naltrexone.

Contraindicated 

in patients who 

are hypersensitive 

to methadone 

hydrochloride 

or any other 

ingredient in 

methadone 

hydrochloride 

tablets, diskettes, 

powder or liquid 

concentrate. 

Contraindicated 

in patients with 

respiratory 

depression (in 

the absence of 

resuscitative 

equipment or 

in unmonitored 

settings) and in 

patients with 

acute bronchial 

asthma or 

hypercarbia.

Contraindicated 

in any patient 

who has or is 

suspected of 

having a 

paralytic ileus.

Contraindicated in 

patients who are 

hypersensitive to 

buprenorphine 

or naloxone.
79

Appendix 4: Key Features of Medications Approved for Treating Opioid Use Disorders

Prescribing 

Considerations

Extended-Release 

Injectable Naltrexone

3 Methadone

4 Buprenorphine5

Warnings Use with caution in 

patients with active liver 

disease, moderate to 

severe renal impairment, 

and women of 

childbearing age. 

Discontinue in the event 

of symptoms or signs of 

acute hepatitis.

As with any IM injection, 

extended-release 

injectable naltrexone 

should be used with 

caution in patients with 

thrombocytopenia or 

any coagulation disorder 

(e.g., hemophilia, severe 

hepatic failure); such 

patients should be 

closely monitored for 

24 hours after naltrexone 

is administered.

Patients may become 

sensitive to lower 

doses of opioids after 

treatment with extendedrelease injectable 

naltrexone. This could 

result in potentially 

life-threatening opioid 

intoxication and 

overdose if previously 

tolerated larger doses are 

administered. 

Clinicians should warn 

patients that overdose 

may result from trying 

to overcome the opioid 

blockade effects of 

naltrexone.

Methadone 

should be used 

with caution 

in elderly and 

debilitated 

patients; patients 

with head injury 

or increased 

intracranial 

pressure; patients 

who are known 

to be sensitive 

to central 

nervous system 

depressants, such 

as those with 

cardiovascular, 

pulmonary, renal, 

or hepatic disease; 

and patients 

with comorbid 

conditions or 

concomitant 

medications that 

may predispose 

to dysrhythmia 

or reduced 

ventilatory drive.

Methadone 

should be 

administered 

with caution 

to patients 

already at risk 

for development 

of prolonged QT 

interval or serious 

arrhythmia.

The label includes 

a warning about 

somnolence 

that may 

preclude driving 

or operating 

equipment.

Caution is required 

in prescribing 

buprenorphine to patients 

with polysubstance 

use and those who 

have severe hepatic 

impairment, compromised 

respiratory function, or 

head injury.

Significant respiratory 

depression and 

death have occurred 

in association with 

buprenorphine, 

particularly administered 

intravenously or in 

combination with 

benzodiazepines or other 

central nervous system 

depressants (including 

alcohol). 

Buprenorphine may 

precipitate withdrawal if 

initiated before patient 

is in opioid withdrawal, 

particularly in patients 

being transferred from 

methadone.

The label includes 

a warning about 

somnolence that may 

preclude driving or 

operating equipment.
80

Appendix 4: Key Features of Medications Approved for Treating Opioid Use Disorders

Prescribing 

Considerations

Extended-Release 

Injectable Naltrexone3 Methadone4 Buprenorphine5

Use in Pregnant 

and Postpartum 

Women

Pregnancy: 

FDA pregnancy 

category C8

Nursing: Transfer 

of naltrexone and 

6ß-naltrexol into 

human milk has 

been reported with 

oral naltrexone. 

Because animal 

studies have shown 

that naltrexone 

has a potential for 

tumorigenicity 

and other serious 

adverse reactions 

in nursing infants, 

an individualized 

treatment decision 

should be made 

whether a nursing 

mother will need 

to discontinue 

breast feeding 

or discontinue 

naltrexone. 

Pregnancy: 

FDA pregnancy 

category C8

Methadone has been 

used during pregnancy 

to promote healthy 

pregnancy outcomes 

for more than 40 years. 

Neonatal abstinence 

syndrome may occur 

in newborn infants of 

mothers who received 

medication-assisted 

treatment with 

methadone during 

pregnancy. Individualized 

treatment decisions 

balancing the risk and 

benefits of therapy should 

be made with each 

pregnant patient.

Nursing: Mothers 

maintained on 

methadone can 

breastfeed if they are 

not HIV positive, are not 

abusing substances, and 

do not have a disease 

or infection in which 

breastfeeding is otherwise 

contraindicated. 

Pregnancy: 

FDA pregnancy 

category C8

Neonatal abstinence 

syndrome may occur 

in newborn infants 

of mothers who 

received medicationassisted treatment 

with buprenorphine9

during pregnancy. 

Individualized treatment 

decisions balancing the 

risk and benefits 

of therapy should 

be made with each 

pregnant patient.

Nursing: Buprenorphine 

and its metabolite 

norbuprenorphine are 

present in low levels in 

human milk and infant 

urine. Available data 

are limited but have not 

shown adverse reactions 

in breastfed infants.

Potential for 

Abuse and 

Diversion

No Yes Yes

8

 In December 2014, the FDA published the Requirements for Pregnancy and Lactation Labeling Rule. The nomenclature is not 

used in the final rule, which requires the removal of the Pregnancy Categories A, B, C, D, and X from all human prescription 

drug and biological product labeling. Labeling is based on descriptive subsections for pregnancy exposure and risk, lactation, 

and effects to reproductive potential for females and males. Retrieved from http://www.gpo.gov/fdsys/pkg/FR-2014-12-04/

pdf/2014-28241.pdf (accessed August 19, 2015).

9

 Buprenorphine without naloxone is recommended for use in pregnancy.
81

Appendix 5: CHARM Collaborative Case Study

Appendix 5: Children and Recovering Mothers (CHARM) 

Collaborative in Burlington, Vermont: A Case Study

Disclaimer: The views, opinions, and content of this publication are those of the authors and do 

not necessarily reflect the views, opinions, or policies of the Substance Abuse and Mental Health 

Services Administration (SAMHSA) or of the U.S. Department of Health and Human Services (HHS). 

Resources listed in this document are not all-inclusive and inclusion in this list does not constitute 

an endorsement by SAMHSA or HHS.

Overview and Purpose

The purpose of this document is to provide an in-depth case study of a community-developed, 

coordinated, and comprehensive approach to caring for families affected by opioid use disorders 

(e.g., heroin or opioid prescription medications). The Children and Recovering Mothers (CHARM) 

Collaborative in Burlington, Vermont, is a multidisciplinary group of agencies serving women with 

opioid use disorders and their families during pregnancy and infancy. This report describes and 

examines two aspects of the CHARM Collaborative: (1) the multiple points of intervention for 

families and (2) the elements of collaborative practice across systems.

There are multiple intervention opportunities for pregnant women with opioid use disorders 

and their newborns across service systems and professionals, beginning before pregnancy 

and continuing throughout a child’s developmental milestones. The National Center on 

Substance Abuse and Child Welfare, funded by the Substance Abuse and Mental Health Services 

Administration (SAMHSA) and the Administration for Children and Families, created a five-point 

framework that addresses screening, assessment, referral, and engagement across all stages of 

development for affected children (Young et al., 2009). According to the framework, interventions 

can reduce the potential harm of prenatal and postnatal substance exposure at five intervention 

points: (1) before pregnancy, (2) during pregnancy, (3) at birth, (4) during the neonatal period, and 

(5) throughout childhood and adolescence.

The case study narrative in this report describes the history of CHARM and the policies and practices 

developed across the intervention points in the five-point framework. This document also provides 

examples of collaborative practices implemented by CHARM. Collaborative practice can be 

defined as the use of 10 system linkage elements by two or more systems, agencies, or providers to 

improve child and family outcomes (Children and Family Futures, 2011). The 10 elements of system 

linkages are: (1) underlying values and principles of collaboration, (2) screening and assessment, (3) 

engagement and retention in care, (4) services to children of parents with substance use disorders, 

(5) joint accountability and shared outcomes, (6) information and data systems, (7) budgeting 

and program sustainability, (8) training and staff development, (9) collaboration with related 

agencies, and (10) collaboration with the community and supporting families. This report examines 

CHARM Collaborative practices across the 10 elements of system linkage. State and community 

collaborative groups can use this information to guide their efforts to implement collaborative 

practices in their own communities.
82

Appendix 5: CHARM Collaborative Case Study

A. History and Description of the CHARM Collaborative

Early Need

In 1998, a physician specializing in addiction 

at the Fletcher Allen Health Care Hospital in 

Burlington, Vermont, met a young pregnant 

woman who was seeking treatment for an opioid 

use disorder, because she was concerned about 

her baby. The physician knew that medicationassisted treatment (MAT) was the best option for 

the woman and her unborn child, and he wanted 

to prescribe methadone. At that time, however, 

no methadone clinics or opioid treatment 

programs (OTPs) existed in Vermont, and the 

Controlled Substances Act of 1970 limited the 

ability of physicians to prescribe methadone 

directly to patients.

Under the Controlled Substances Act of 1970, 

physicians could request waivers from the 

State Opioid Treatment Authority to prescribe 

methadone to identified patients as part of their 

medical practice. The Burlington physician applied for and received a waiver for the first woman. 

Within a year, he received waivers to treat two additional pregnant women who had opioid use 

disorders. The demand for treatment grew quickly, so the physician continued to request and 

obtain waivers to treat several pregnant women, until the first methadone clinic in Vermont opened 

in 2002 at Fletcher Allen Health Care Hospital. This physician worked with an obstetrician and 

neonatologist from this hospital to coordinate care for pregnant women with opioid use disorders.

Burlington, Vermont

The population of Vermont is 

approximately 626,000, and the 

population of Burlington, the state’s 

largest city, is approximately 42,000. 

Burlington lies on Lake Champlain 

in the northwest part of the State. 

The University of Vermont Medical 

Center (formerly Fletcher Allen 

Health Care Hospital) is the only 

hospital in Burlington. 

Creation of the CHARM Collaborative

These early efforts to provide care for women with opioid use disorders during pregnancy became 

the CHARM Collaborative. Today, CHARM provides comprehensive care coordination for pregnant 

women with opioid use disorders and consultation for child welfare, medical, and addiction 

professionals across Vermont. In 2013, the CHARM Collaborative supported 194 women and their 

infants and families.

Effectively treating and supporting pregnant women with opioid use disorders and their families 

requires a comprehensive approach. Before the CHARM Collaborative was formally established in 

2002, two groups of professionals worked together to coordinate care for their shared patients in 

Burlington.

At Fletcher Allen Hospital, an addiction specialist joined two other physicians from the 

Comprehensive Obstetric and Gynecological Specialty (COGS) clinic and the Neonatal Medical 

Follow-up Clinic (NeoMed) at the hospital to address the needs of the families they were treating. 

This group’s primary goal was to make sure that each woman with an opioid use disorder and her 

infant received the services they needed, including substance abuse counseling, nutrition support 

from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and 

home-visiting services for prenatal and early childhood support.
83

Appendix 5: CHARM Collaborative Case Study

Members of a second group of community-based professionals were also working together to 

support pregnant women with opioid use disorders and their families; they were from Lund1, a 

comprehensive treatment center and family support agency; the Howard Center, a substance abuse 

treatment provider; and the State Alcohol and Drug Abuse Program (ADAP).

By 2002, the two groups had begun working together informally. At that time, the demand for 

access to MAT for pregnant women (among other populations) was continually growing. Several 

state agencies, such as the Division of Maternal and Child Health’s ADAP (including the Women’s 

Treatment Programs and Opioid Treatment Authority), began discussing ways to address these 

emerging issues with the U.S. Drug Enforcement Agency. The efforts of this group resulted in two 

critical outcomes: (1) the development of the first methadone clinic in Vermont and (2) the decision 

to provide an outside facilitator from the KidSafe Collaborative of Chittenden County, Vermont, 

to help the two informal groups establish a more formal care-coordination effort. The KidSafe 

Collaborative supports multiple cross-agency collaborations to prevent and address child abuse and 

neglect in Burlington.

The six initial members of the collaborative were a physician and addiction specialist, an 

obstetrician, a neonatologist, the ADAP women’s services coordinator, and the directors of 

Lund and the Howard Center. This team served many families who were receiving child welfare 

services from the Vermont Department of 

Children and Families (VDCF), and the group 

wanted VDCF representatives to join the 

collaborative. However, the addition of VDCF 

created conflicts among collaborative members, 

primarily regarding information sharing. Many 

collaborative members were unsure of how to 

share patient information while still adhering 

to confidentiality laws and regulations. For 

example, under federal mandates to protect 

child safety, VDCF was obligated to act on any 

information revealing potential child safety 

concerns. Substance abuse treatment providers 

were also reluctant to share client information 

that might put their clients at risk of involvement 

in the child welfare system. Collaborative 

members agreed that all stakeholders needed 

to be at the table to ensure child safety and 

promote family well-being, so they made a 

commitment to identify a solution to this 

information-sharing challenge. VDCF was 

ultimately able to participate in the collaborative.

To address this confidentiality concern, the 

collaborative created a memorandum of 

understanding (MOU; see Attachment A: CHARM 

Collaborative Memorandum of Understanding) and 

1

 Lund Family Center is a comprehensive residential and community treatment program for women with substance use 

disorders and their children who also participated in Round I of the Regional Partnership Grants (RPG-I) program administered 

by Children’s Bureau, Administration for Children and Families, Department of Health and Human Services. More information 

about Lund’s participation in the RPG-I program can be found at https://www.ncsacw.samhsa.gov/technical/rpg-i.aspx?id=101.

Vermont Statute

Title 33: Human Services

Chapter 49: Child Welfare Services

§4917. Multidisciplinary Teams; 

Empaneling

The Commissioner or his or 

her designee may empanel a 

multidisciplinary team or a special 

investigative multitask force team 

or both wherever in the state there 

may be a probable case of child 

abuse or neglect which warrants 

the coordinated use of several 

professional services. These teams 

shall participate and cooperate with 

the local special investigation unit 

in compliance with 13 [Vermont 

Statutes Annotated] § 5415.
84

Appendix 5: CHARM Collaborative Case Study

a comprehensive, multiagency release-of-information form2 (see Attachment B: CHARM Collaborative 

Release of Information) for clients to sign that would allow members to appropriately share 

information for care-coordination purposes. Collaborative members and their agencies’ attorneys 

spent two years negotiating the terms of the MOU and release-of-information form. Skilled 

facilitation provided by KidSafe and the ongoing commitment of all members to effectively serve 

pregnant women with opioid use disorders and their families were critical factors in the eventual 

success of this effort.

Another part of the solution to the information-sharing challenge came from a state statute that 

provides for the development of child protection teams that may share client information under 

certain circumstances. Similar statutes exist in other states and might offer policy opportunities 

to communities interested in creating a model similar to the CHARM Collaborative. The Vermont 

statute (Title 33, Section 4917) allows a group of empaneled professionals to share relevant, clientspecific information with one another for the purpose of ensuring child safety. Establishing an 

empaneled group required approval for each member from the commissioner of the VDCF. Once 

each CHARM Collaborative member received this approval, the group became a designated child 

protection team. Effective information sharing allowed the group to coordinate services for families 

with child safety concerns successfully.

Another significant early challenge for CHARM was the limited availability of MAT in Vermont. 

Initially, the State Opioid Treatment Authority required physicians to obtain a one-time waiver to 

prescribe methadone for each pregnant woman. In 2002, the State Opioid Treatment Authority 

established the first state-approved OTP at Fletcher Allen Hospital in Burlington. This OTP 

dispensed methadone from the hospital pharmacy to women who arrived daily for their prescribed 

dose. Later, the methadone program moved to a community-based clinic. In 2004, buprenorphine 

became a second option for MAT during pregnancy in Vermont. In Burlington, buprenorphine 

prescriptions and dosing became available at the Fletcher Allen Hospital’s COGS, where many 

CHARM women received prenatal care. State approval for the first OTP and for buprenorphine use 

effectively increased access to MAT for pregnant women in Vermont.3

2

 The release-of-information form provided in this document is a sample and is not endorsed by SAMHSA or HHS.

3

 At the writing of this report, state-approved OTPs exist in all states, except for Wyoming and North Dakota. For more 

information on OTPs, including a state directory, certification requirements, and a list of opioid treatment authorities, see http://

dpt2.samhsa.gov/treatment/directory.aspx.
85

Appendix 5: CHARM Collaborative Case Study

CHARM Today

Today, the CHARM Collaborative includes 10 organizations that collectively provide comprehensive 

care coordination for pregnant women with opioid use disorders and consultation for child welfare, 

medical, and addiction professionals across Vermont. Several members have been involved in 

CHARM since the group’s inception. The following table lists the CHARM Collaborative members.

Member Organization Services Provided

Comprehensive Obstetric and 

Gynecological Services (COGS), 

Fletcher Allen Health Care Hospital

§ Prenatal care

§ MAT assessment

§ Buprenorphine treatment

§ Care coordination

NeoMed Clinic, Vermont Children’s Hospital 

at Fletcher Allen Health Care Hospital

§ Neonatal assessment and treatment

§ Parent education on neonatal 

abstinence syndrome

§ Developmental assessment

Howard Center/Chittenden Clinic

§ MAT assessment

§ Methadone and 

buprenorphine treatment

§ Individual and group substance 

abuse treatment

Lund

§ Residential care for mothers and 

infants

§ Substance abuse treatment

§ Parent and family support

Vermont Department for Children 

and Families

§ Child safety assessments

§ Child welfare services

Vermont Department of 

Corrections/Correct Care Solutions

§ Health care for women in the 

corrections system

Alcohol and Drug Abuse Programs, 

Vermont Department of Health 

§ Substance abuse treatment

§ Opioid Treatment Authority
86

Appendix 5: CHARM Collaborative Case Study

Member Organization Services Provided

Maternal and Child Health Programs 

(Chittenden, Franklin, and Grand Isle 

Counties), Vermont Department of Health

§ Public health services

§ Special Supplemental Nutrition 

Program for Women, Infants, and 

Children (WIC)

§ Home-visiting referrals

Vermont Department of Health Access § Medicaid coverage

Visiting Nurse Association of Chittenden 

and Grand Isle § Nurse home-visiting services

At any given time, approximately 100 women receive coordinated care through the CHARM 

Collaborative. Each month, about 20 pregnant women are added to the client list and about 10 

newborns are delivered. Annually, the collaborative serves 200–250 families.

Members of the CHARM Collaborative meet once a month for two hours to discuss the needs of 

client families and how to address these needs. Decisions about solutions and follow-up tasks 

are made for each family before the next family is discussed. To support these discussions, the 

facilitator distributes a list of client families at each meeting. These lists are divided into four 

categories of families: (1) new to CHARM, (2) with a woman expected to give birth within 30 

days, (3) with a woman who recently gave birth, and (4) about whom a collaborative member has 

concerns. Within each category, the names are listed alphabetically, and families are discussed 

in that order. Typically, about 40 families are discussed at each meeting. Periodically, the first 15 

minutes are used for providing cross-disciplinary 

training, sharing outcomes, and discussing related 

projects and other process issues that are not case 

specific.

With 40 families to discuss in less than two hours, 

the meeting process needs to be quick and 

effective. CHARM’s many years of experience 

working as a collaborative is one of the key factors 

that helps them use their time effectively. Other 

key factors include having a skilled facilitator at 

each meeting and having immediate access to 

current client files. Many members have remote 

access to their case files while participating in the 

meetings.

Decisions about follow-up with client families 

made during meetings might include increasing 

care coordination, intensity of services, and social 

supports as well as formally submitting a report to 

VDCF or requesting a VDCF safety assessment.

Critical Facilitator Competencies

An effective facilitator is:

§ Organized

§ Objective (not partial to certain 

members)

§ Effective at oral and written 

communication

§ Aware of relationships among 

group members and political 

influences on the group

§ Adept at conflict resolution
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Appendix 5: CHARM Collaborative Case Study

Organizing and maintaining the CHARM Collaborative process requires the efforts of several key 

individuals, including the facilitator, a NeoMed nurse, and COGS and NeoMed caseworkers. Each 

individual plays a key role in sustaining the overall effort.

The facilitator (who is from KidSafe Collaborative) guides the CHARM Collaborative. She is 

responsible for developing the CHARM meeting agendas, facilitating CHARM Collaborative 

meetings, managing conflicts among CHARM members, monitoring the empanelment process 

for the child protection teams, managing the budget of the CHARM Collaborative, developing 

resources, and managing communication among collaborative members. Along with other CHARM 

Collaborative members, the facilitator gives presentations at conferences throughout the country 

on the CHARM process and lessons learned. Her knowledge of child welfare issues and policies and 

her communication and facilitation skills allow her to objectively and effectively assist the CHARM 

Collaborative in addressing the needs of each family, while protecting client rights and respecting 

the mandates of each member organization. The facilitator spends about four hours per week 

on CHARM, and her time is supported financially by a combination of small grants from private 

foundations, United Way, and the Vermont Division of Alcohol and Drug Abuse Programs. The state 

funding for the facilitator is discretionary, and the amount varies from year to year. 

The neonatal nurse monitors the release-of-information forms and maintains the list of CHARM 

families. Her efforts for CHARM require about one hour per week, and Fletcher Allen Health Care 

Hospital provides her services on an in-kind basis.

The social worker at the COGS clinic works primarily with CHARM families, taking on most of the 

care coordination responsibilities for these families during pregnancy. The medical assistant and 

the nurse in the NeoMed clinic provide most of the care coordination for families during infancy. 

They work with CHARM families in addition to other families who receive neonatal services. Fletcher 

Allen Health Care Hospital supports these three positions. If the CHARM Collaborative did not 

exist, COGS and the NeoMed clinics would still provide care coordination services for these families, 

but the CHARM Collaborative improves the efficiency of this care coordination and decreases the 

amount of time it requires.

Benefits of CHARM

The CHARM Collaborative benefits families, 

organizations, the community, and the State of 

Vermont. This collaborative has resulted in a full 

range of services for the families of pregnant 

women with opioid use disorders in the northern 

half of the state. Collaborative members have 

shared the CHARM process throughout the 

state, and other counties are now implementing 

similar models. For the organizations involved in 

CHARM, the time saved by coordinating services 

for 40 families in one 2-hour meeting a month 

(compared with the time required to coordinate 

services by telephone and e-mail) is substantial, 

and members believe that the quality of care 

they provide to families is better as a result. The CHARM process avoids problems resulting from 

conflicting information about patient health, progress in recovery, and behavior. Family needs are 

identified sooner and addressed more quickly, and fewer families “fall through the cracks” than if the 

services these families received were not coordinated among providers.

“With CHARM, there is a time and 

space set aside so we can tie up 

loose ends and make sure families 

are doing okay. If they are not, 

we can act quickly and prevent or 

address child safety concerns.” 

 -CHARM Collaborative member
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Appendix 5: CHARM Collaborative Case Study

The benefits of CHARM to families include 

healthier pregnancies, healthier children, and a 

greater chance of remaining together or being 

reunified. Since CHARM began, access to MAT for 

pregnant women has increased, and women are 

receiving treatment earlier in their pregnancies. 

There is a trend toward increased birth weight 

and fewer newborns requiring pharmacological 

treatment for withdrawal symptoms after 

discharge from the hospital. Newborns who do 

require treatment after discharge are able to 

complete their treatment at home.

In 2012, a study led by one of the COGS 

obstetricians and published in the Journal of 

Addiction Medicine identified some outcomes 

of the CHARM Collaborative (Meyer, Benvenuto, 

Howard, Johnston, Plante, Metayer, & Mandell, 

2012). The authors investigated the impact that 

increased access to MAT had for women and 

infants served by CHARM from 2000 to 2006. 

Of the 106 CHARM infants who underwent 

developmental screening at eight months, 96 

(94 percent) were within normal limits on all 

developmental parameters, six (5.6 percent) had 

mild delays, two (1.8 percent) had more severe 

delays, and two (1.8 percent) died after discharge 

from the hospital.4

 Of 134 CHARM newborns delivered between 2003 and 2006, 116 (86 percent) 

were discharged from the hospital in the custody of the mother. This percentage increased from 

83.3 percent in 2003 to 91.8 percent in 2006.

Over the last several years, CHARM members have identified factors that seem to predict infant 

health in CHARM families. Healthy outcomes in infants are more likely when women obtain prenatal 

care early during pregnancy, consistently complete their prenatal visits, receive MAT, participate 

in counseling, and/or attend at least one prenatal appointment with a neonatologist. Conversely, 

poor health outcomes for the baby are more likely when women miss prenatal and neonatal 

appointments, continue their illicit use of opioids, lack stable housing, and/or do not continue to 

obtain substance abuse counseling (even if they continue to undergo MAT).

Factors Resulting in Healthier 

Infants

§ Access to early prenatal care

§ Consistent attendance of 

prenatal visits

§ Receipt of MAT and counseling

§ Completion of at least one 

prenatal or neonatal visit

Factors Resulting in Less Healthy 

Infants

§ Missed prenatal and 

neonatal appointments

§ Continued use of illicit opiates

§ Lack of stable housing

§ Discontinuation of counseling 

(even if the woman continues 

to receive MAT)

B. Engaging Mothers during Pregnancy

This section describes the decision-making process and services of the CHARM Collaborative across 

three time frames: pregnancy, birth, and after birth. 

Members of the CHARM Collaborative have identified four goals for each family during pregnancy: 

(1) engage each woman in prenatal care as early in the pregnancy as possible, (2) reduce opioid 

cravings and withdrawal symptoms using MAT, (3) engage each woman (and her partner if possible) 

in substance abuse counseling, and (4) provide social support and meet basic needs for the family.

4

 Neither of the infants who died required treatment for neonatal abstinence syndrome. The mothers of both infants 

were actively receiving substance abuse treatment, with no indication of relapse. The causes of death were suffocation 

from co-sleeping and sudden infant death syndrome.
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Appendix 5: CHARM Collaborative Case Study

Prenatal Care

Most pregnant women enrolled in CHARM are referred to COGS for prenatal care by another 

CHARM Collaborative member. They can also be referred by a hospital emergency department staff, 

community obstetrician, primary care provider, or substance abuse counselor. Women can also refer 

themselves to COGS for prenatal care. If a woman is referred by an emergency department, COGS 

will schedule an appointment for her for the next business day. COGS staff regard this situation as 

urgent but not as an emergency requiring immediate action.

The goals for a CHARM woman’s first visit to COGS for prenatal care are to confirm the pregnancy; 

assess the woman’s opioid use disorder and whether she needs MAT; assess her nutrition status and 

refer her to WIC for nutrition support, if needed; and begin assessing her social support needs. Most 

CHARM women receive referrals for home-based well-baby services. If the pregnancy and/or opioid 

use disorder is not confirmed, the woman is referred to other services based on her needs, and the 

family is not added to the CHARM client list.

CHARM women can also receive prenatal care from community-based obstetricians or primary care 

providers. The number of CHARM women receiving prenatal services from non-COGS providers 

is growing, as the number of providers receiving training and improving their competency in 

using MAT during pregnancy increases. In some cases, women receive early prenatal care from 

community providers and transfer to COGS later in the pregnancy for closer monitoring and 

coordinated care.

Prenatal Care at COGS

The COGS Team

Four staff members provide services to CHARM women at COGS: a physician, a registered nurse, a 

medical assistant, and a medical social worker. All four staff members work to engage and retain 

the pregnant women with opioid use disorders in prenatal care and substance abuse treatment, 

including MAT. Two of the four COGS staff members attend CHARM meetings every month.

The physician has in-depth knowledge of addiction through years of experience and a close 

association with a physician who has specialized in addiction medicine. The physician attends 

relevant conferences and continuing education events. In the early days of the CHARM 

Collaborative, all CHARM women received a consultation with the addiction medicine specialist. 

Currently, the obstetrician requests consultations with the addiction medicine specialist only for 

complicated or unusual situations.

The nurse communicates regularly with the CHARM facilitator. The nurse also coordinates 

information dissemination and services for CHARM families with the physician, medical assistant, 

and social worker.

The medical assistant generates lists of new patients for the facilitator each month and identifies 

families to be discussed by the COGS team at monthly CHARM meetings.

The medical social worker coordinates medical care, substance abuse treatment, social supports, 

and nutrition services for CHARM families. She also educates parents about CHARM and requests 

a signed release-of-information form from families that enroll in the program. She relies on the 

CHARM meetings to efficiently coordinate services with other providers for CHARM clients.

CHARM Services Provided at COGS

CHARM women receive prenatal care services at COGS, and the frequency of these visits depends 

on gestational age and whether the women have complications that need monitoring. In addition 

to standard prenatal care, each visit includes giving a urine drug test; monitoring the attendance of 
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Appendix 5: CHARM Collaborative Case Study

prior prenatal visits; offering substance abuse counseling; scheduling NeoMed and home-visiting 

appointments; and assessing social support needs regularly, including housing, transportation, and 

mental health services. All CHARM women are tested for HIV, gonorrhea, chlamydia, and hepatitis 

B and C at their first visit to COGS. COGS offers CHARM women hepatitis B immunizations after the 

first trimester. The women are tested again for gonorrhea and chlamydia at 28 weeks of gestation 

and for hepatitis C during the third trimester. The women are also given a group B streptococcus 

test at 35 weeks.

COGS team members also encourage the partners of CHARM mothers to seek substance abuse 

treatment when needed and can assist in coordinating referrals and assessments for them. The 

COGS team refers CHARM women to services and supports as needed or documents these needs to 

discuss at the next CHARM meeting.

At each prenatal visit, the physician, nurse practitioner, medical assistant, and social worker monitor 

the woman’s behavior for indications of a relapse or a need to adjust the MAT dosage. The COGS 

team can adjust MAT doses immediately, when needed, for women receiving MAT at COGS. For 

women receiving MAT from another provider, COGS staff contact that provider immediately, without 

waiting for the next CHARM meeting.

Women receive an ultrasound during an early prenatal care visit. Seeing the baby is often a 

significant motivator for women to protect their health and stay engaged in substance abuse 

treatment. The ultrasounds also allow the physician to identify any anomalies in the fetus. 

Additional ultrasounds are done each trimester.

MAT

CHARM women have several options for receiving MAT during pregnancy. If a pregnant woman is 

already stable on MAT, she is likely to stay with the same MAT provider throughout her pregnancy. 

However, most pregnant women are not stable on MAT when they come to the attention of the 

CHARM Collaborative.

A MAT assessment is typically completed at COGS or a methadone clinic in accordance with the 

Vermont MAT guidelines for pregnant women. For providers who are determining whether to 

prescribe buprenorphine or methadone, the Vermont guidelines recommend basing the decision 

on the answers to several questions, such as:

§ Is the woman able to take 

medication consistently on her 

own?

§ Is she able to follow safety 

procedures?

§ Does she need a high level 

of structure to be successful 

in complying with the 

medication prescription (and 

is it helpful to require her to 

go to the clinic every day to 

receive methadone)?

§ What is her living situation?

§ Which medication does she prefer?

Treatment of Opioid Dependence in Pregnancy, 

Vermont Guidelines

A consolidated set of recommendations for the 

management of opioid use disorders during 

pregnancy. Developed by the Vermont Child Health 

Improvement Program. Available at: https://www.

uvm.edu/medicine/vchip/?Page=perinataltools.html
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Appendix 5: CHARM Collaborative Case Study

Methadone

Burlington and the surrounding areas have one primary methadone provider. This methadone 

clinic was the first to open in Vermont, and its medical director is the addiction-certified physician 

who advocated for MAT for pregnant women prior to the existence of CHARM.

Induction on methadone can be provided to CHARM women on an outpatient basis at this clinic or 

at the hospital over a 2- or 3-day admission, if needed for medical reasons. The dosage is adjusted 

frequently, until the women are stable and relatively symptom free. After the induction period, 

the provider adjusts the dosage as needed, based on patient reports and observed behavior. At 

first, patients must visit the clinic daily for dosing. As of January 2013, in accordance with federal 

regulations, women can receive their doses on a weekly basis, once their condition is stable.

Buprenorphine

Most CHARM women with a buprenorphine prescription receive the medication from the COGS 

clinic on a weekly basis. Due to a statewide initiative implemented in 2013, known as the Hub 

and Spoke Initiative (see Attachment C: Hub and Spoke Initiative), CHARM women can also 

receive buprenorphine from the state’s methadone clinic or other community-based providers. 

Buprenorphine induction by COGs takes place during a 24-hour hospital admission.

CHARM Release-of-Information Form

Following a woman’s induction and initial stabilization with MAT, a CHARM member (at COGs or 

the methadone clinic) informs her about the CHARM Collaborative and requests her signature on a 

comprehensive release-of-information form. By signing this form, the woman becomes a CHARM 

client. The vast majority of eligible 

women sign the informationrelease form.

The small number of women 

who choose to not participate in 

CHARM receive the same care from 

most of the same providers as 

CHARM participants but with only 

standard care coordination. The 

service needs, health, and recovery 

progress of non-CHARM women 

are not discussed at CHARM 

meetings until 30 days before their 

expected due date. At that time, if 

any group member has concerns 

about the safety of a patient’s baby, that group member submits a report to VDCF, and the group 

operates under its authority as an empaneled child protection team, in compliance with all relevant 

information-sharing protocols. As providers develop relationships and build trust with women not 

enrolled in CHARM and their families, the providers continue sharing information about the CHARM 

Collaborative, and many of the pregnant women with opioid 

use disorders ultimately agree 

to participate.

The Hub and Spoke Initiative 

(http://healthvermont.gov/adap/documents/

HUBSPOKEBriefingDocV122112.pdf) is a 

coordinated, systemic response to the 

complex issues of opioid and other substance 

abuse disorders in Vermont. The Vermont Agency 

of Human Services and community providers 

developed this initiative jointly.

Substance Use Disorder Counseling

All CHARM women who receive MAT must also receive substance use disorder counseling and 

nonpharmacological substance use disorder treatment. Both group and individual treatment are 
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Appendix 5: CHARM Collaborative Case Study

provided to CHARM women through 

programs at the Chittenden Clinic, 

Fletcher Allen Health Care Hospital, 

Lund’s residential care program, and 

other community-based treatment 

providers. CHARM Collaborative 

members treat lack of engagement in 

substance use disorder counseling as 

a risk factor for poor birth outcomes 

for CHARM women, even if the 

woman continues receiving MAT. 

Collaborative members emphasize the 

importance of substance use disorder 

counseling with families and make 

every effort to keep women engaged 

and actively participating in this 

component of their treatment.

Lund is a comprehensive treatment center and 

family-support agency that offers an array of 

integrated services in response to the needs 

of pregnant or parenting teens and women, 

adoptive families, and children. Lund is an active 

member of the CHARM Collaborative, providing 

residential care for women and their babies when 

that level of treatment is indicated and providing 

outpatient substance use disorder counseling to 

many CHARM women.

Neonatal Consultation

An important component of the CHARM process consists of prenatal visits to NeoMed, where 

providers focus on educating women about the health and safety of their newborn; on building a 

relationship; and on establishing trust among NeoMed staff, the woman, and her family. The COGS 

clinic staff refer CHARM women for one or two prenatal consultations with the NeoMed providers. 

COGS clinic staff strongly encourage the women to complete these visits, including sometimes 

accompanying CHARM women to NeoMed to schedule the appointment. 

The NeoMed provider meets with each expectant CHARM woman to discuss the importance of 

prenatal care, what to expect from a newborn, optimal care of the newborn, the potential for 

neonatal abstinence syndrome (NAS), and what NAS assessment and treatment for the woman’s 

infant might require. When discussing care for the infant, the provider and expectant mother talk 

about the importance of skin-to-skin contact, breastfeeding, and a low-stimulus environment, with 

low lighting and noise levels and few visitors. The provider and client also discuss the woman’s 

fears, concerns, strengths, and goals.

Each family receives an “Our Care Notebook,” 

with resources, information, personal stories, 

and encouragement. A quality improvement 

project at the University of Vermont, called 

Improving Care for Opioid-Exposed Newborns 

(ICON), created the Our Care Notebook, with the 

help of several women who had been served by 

the CHARM Collaborative. The ICON team also 

included previous COGS staff and NeoMed staff. 

Collaborative members consider participation 

in one or more prenatal NeoMed consultations 

to be a protective factor for infant well-being. 

Women receiving prenatal care from the COGS 

clinic are more likely to attend prenatal visits 

than those who receive prenatal care elsewhere.

Our Care Notebook

This notebook for mothers of

opiate-exposed newborns provides

information, lists of resources, stories, 

and encouragement. It is available 

for other communities to customize 

at https://www.uvm.edu/medicine/

vchip/?Page=perinataltools.html
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Appendix 5: CHARM Collaborative Case Study

Involvement of the Child Welfare System During Pregnancy

If CHARM women are stable, their pregnancy has no complications, and no concerns exist about 

the safety of the baby, the family is discussed at only two CHARM Collaborative meetings—when 

the family first enters the program and again within 30 days of the woman’s due date. A woman 

is considered stable when she is taking the prescribed MAT with no problems and is attending 

counseling and prenatal visits. The brief discussion of the woman and her family at the second 

CHARM Collaborative meeting (within 30 days of due date) is to confirm the lack of safety concerns. 

At that point, if no safety concerns have been identified, the labor and delivery team is alerted and 

no further actions are taken. VDCF is aware of all families served by the CHARM Collaborative. If 

no concerns have arisen regarding a CHARM woman’s infant, VDCF does not conduct a safety risk 

assessment of that woman and her family.

If a CHARM woman is not stable on MAT, continues to use illegal substances during her pregnancy, 

is not attending substance use disorder counseling or prenatal visits, and/or does not have a safe 

and stable living situation, the safety of her baby becomes a concern. Depending on the level of 

concern, CHARM Collaborative members might refer the case to VDCF prior to the baby’s birth and/

or refer the woman and her child(ren) to a residential care facility for more intensive treatment and 

greater structure and safety.

In Vermont, unlike most other states, the child welfare system can initiate a safety and risk 

assessment prior to a woman’s due date. If VDCF receives a report of prenatal substance exposure 

or a pregnant woman admits using illegal drugs or nonprescribed medications during the third 

trimester, the agency places the report on a “high-risk” calendar. At 30 days prior to the expected 

due date, VDCF initiates a risk and safety assessment, and if indicated, a caseworker begins 

providing supportive services to the family.

Women served by the CHARM Collaborative receive frequent drug tests. If a woman has had 

multiple positive test results, a collaborative member typically submits a report to VDCF before the 

third trimester.

Collaborative members consider the implementation of the state policy of allowing early safety 

and risk assessments to be conducted to be one of the most significant and beneficial system-level 

changes that have resulted from CHARM. VDCF workers can create safety plans, provide services, 

and when necessary, arrange alternative placements well in advance of hospital discharge for new 

mothers. This minimizes the need for emergency custody orders and improves service planning 

with families and providers.

The child safety assessments of families affected by prenatal substance exposure are completed 

using the same protocol as that used for all families reported to VDCF for any reason. Similarly, 

the individualized child safety interventions 

provided to CHARM families of infants with 

prenatal substance exposure or parental 

prescriptions for MAT are the same as 

those provided to other families. CHARM 

Collaborative members may share the results 

of safety assessments and intervention plans 

with other collaborative members, and all 

members who are working with a family share 

their observations regarding the family’s 

progress, success, concerns, and needs.

Early Intervention

CHARM Collaborative members consider 

the provision of services by the child 

welfare system 30 days prior to the 

child’s birth to be one of the most 

significant and beneficial system-level 

changes that the collaborative has made.
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Appendix 5: CHARM Collaborative Case Study

C. During Birth and the Hospital Stay

Services Provided at Birth

CHARM women may give birth in any hospital, but most deliver at Fletcher Allen Health Care 

Hospital in Burlington. The CHARM facilitator alerts all collaborative members of expected deliveries 

within the next 30 days. The hospital social worker contacts VDCF if any child safety concerns arise 

at the time of birth. In most cases, the identification and planning of the needs for alternative 

placements for the baby or additional supports for families to adequately care for the baby take 

place prior to labor and delivery.

Labor and delivery protocols are the same for all women giving birth at this hospital, except that 

the focus on pain control increases, because women taking buprenorphine or methadone often 

experience higher levels of pain during childbirth. Medical providers report no evidence of drugseeking behavior during labor and delivery for CHARM women.

Hospital staff do not screen all CHARM mothers or newborns at birth for illegal substance use or 

exposure. CHARM women undergo regular drug tests, so screening at birth would not provide any 

new information. Toxicology screening for women and newborns who are not part of the CHARM 

Collaborative is ordered by the attending pediatrician or neonatologist, based on observed behavior 

in the mother and/or withdrawal symptoms in the baby.

If hospital staff suspect substance use in a mother and exposure in a baby who are not part of 

CHARM, they speak with the mother about their concerns. Depending on the response, staff might 

order a toxicology screen of the mother. If her results are positive for an illegal or nonprescribed 

substance, hospital staff submit a report to VDCF, who completes a child safety assessment. If the 

mother denies use of illicit or nonprescribed substances during pregnancy and concerns about the 

baby remain, a toxicology screen may be ordered for the baby. Parental permission is not required in 

this situation. If the results are positive, a report is submitted to VDCF, and the hospital social worker 

meets with the mother to discuss the toxicology 

test results and the implications of the report to 

VDCF. The social worker describes the CHARM 

Collaborative and asks the woman to sign the 

comprehensive release-of-information form and 

enroll in the CHARM program.

Toxicology Screening at Birth

Eliminating duplicative and 

unnecessary drug tests reduces 

stigma, improves collaborative 

practice, and decreases costs. Infant Care, NAS Assessments, and Treatments

All CHARM newborns stay in their mother’s room 

after birth. CHARM mothers are encouraged to 

use nonpharmacological treatments for their 

infants’ withdrawal symptoms, including skin-toskin contact, breastfeeding, and a low-stimulus 

environment (i.e., low levels of light and noise and 

few visitors).

CHARM infants typically stay in the hospital for 4–6 days and are cared for by hospital pediatricians 

or the mother’s own pediatrician, if that individual has hospital privileges. A nurse or medical 

assistant from NeoMed visits each CHARM mother in the hospital to hand deliver a NeoMed 

appointment slip for one or two weeks after discharge. These staff also mail an appointment 

reminder to the woman’s home. The NeoMed medical professional does not meet the baby until the 

woman’s first visit to the clinic, unless the baby has complications.
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Appendix 5: CHARM Collaborative Case Study

Hospital nurses assess all CHARM newborns for NAS, 

using a scoring tool based on the Finnegan Neonatal 

Abstinence Scoring System (Finnegan, Connaughton, 

Kron, & Emich, 1975). Assessments begin at two 

hours after birth and continue every three to four 

hours for the first 96 hours until discharge, or if the 

infant receives a NAS diagnosis, until treatment 

begins and the infant’s condition is stable on 

medication. Through a quality-improvement project 

led by ICON, nurses teach parents to observe and 

monitor symptoms of withdrawal in their infants and 

encourage the parents to participate in the NAS assessments during the hospital stay.

Newborns diagnosed with NAS are treated with methadone and remain in the hospital until their 

withdrawal symptoms are safely managed. Their average length of stay is the same as for newborns 

with no need for methadone treatment (4–6 days). Some newborns complete methadone 

treatment and are weaned from it by the time they leave the hospital. Most parents in stable 

recovery for whom there are no child safety concerns and who have infants needing treatment after 

discharge continue administering treatment at home. Parents are trained to administer methadone 

to their infants and must demonstrate the ability to measure the correct dosage before leaving the 

hospital and at each NeoMed appointment. Parents continue to monitor their baby for withdrawal 

symptoms, and the NeoMed provider gives the family a weaning schedule to follow at home.

Parents may call NeoMed staff with questions or concerns at any time. CHARM Collaborative 

members believe that this high level of support is a critical component of the success of the 

collaborative. NeoMed staff do not recommend that other hospitals give parents responsibility for 

administering methadone to a newborn at home unless a similar mechanism is in place to provide 

immediate support by telephone at all times.

Between June 2009 and 

December 2012, 76.7 percent 

of CHARM babies (365 of 476) 

did not require pharmacological 

treatment for withdrawal 

symptoms (Borden, 2013).

Involvement of VDCF and Courts at Birth

The VDCF directs caseworkers to assess mothers when any of the following circumstances occur 

before, at, or shortly after birth:

§ An infant has been born with a positive toxicology screen for illegal substances or prescription 

medication not prescribed to the patient or administered by a physician;

§ A physician certifies or the mother admits to using illegal substances or nonprescribed 

prescription medication during the last trimester of her pregnancy; or

§ Using NAS scoring, a medical professional has deemed an infant has NAS as the result of maternal 

use of illegal substances or nonprescribed prescription medication (VDCF, 2011).

Reports to VDCF under these circumstances lead to safety assessments, and the results are used to 

determine whether a case is opened for ongoing child welfare services. The Federal Child Abuse 

Prevention and Treatment Act requires states to implement policies and procedures to notify child 

protective services agencies of newborns with prenatal substance exposure. In accordance with 

the Child Abuse Prevention and Treatment Act of 2010, VDCF develops a plan to provide safe care 

for these newborns. In Burlington, the plan of safe care is collaboratively developed with VDCF and 

medical staff and social workers at the hospital.

VDCF may open a case for ongoing services, without court involvement, based on the results of 

the safety and risk assessment. As soon as a case is opened, VDCF begins providing services to the 

family. Services might include linkages to home-visiting services; substance use disorder treatment, 

if the mother is not already receiving treatment; residential placement for the mother and baby; or 
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Appendix 5: CHARM Collaborative Case Study

alternative placement for the baby, if needed. The VDCF worker also informs the family about the 

CHARM Collaborative and encourages the mother to sign the comprehensive release-of-information 

form to obtain access to coordinated care. If VDCF seeks custody of the child or a protective order, 

the courts become involved and standard child welfare and legal practice is followed. In this 

situation, the VDCF worker may convey relevant updates, progress, and concerns from CHARM 

Collaborative members to the judge.

D. Infant, Postpartum, and Ongoing Services

Services for Children After Hospital Discharge

All CHARM women are expected to bring their infant for regular visits to NeoMed until the child is 12–

18 months old. The first appointment takes place one or two weeks after the baby’s discharge from 

the hospital. Newborns receiving methadone treatment are scheduled for visits every two weeks, 

visits are less frequent for newborns not on methadone treatment. During these appointments, a 

health care provider measures the baby’s weight and size; conducts a physical examination; monitors 

the infant’s growth and development; and reviews the mother’s MAT dose, receipt of substance 

abuse counseling, and needs for other family supports. In addition, the provider delivers parenting 

education. The parents of newborns receiving methadone treatment at home must bring the 

methadone to each appointment so that health care providers can measure the remaining amount. 

Parents must also demonstrate the ability to measure the correct dosage for their baby.

A community-based pediatrician or primary care provider is responsible for well-baby visits and 

illnesses not related to prenatal exposure. If safety concerns for the baby arise at any time, NeoMed 

staff and/or the pediatrician report the concerns to VDCF. NeoMed staff also share their concerns at 

CHARM meetings.

Services for Women and Families

The COGS clinic provides services to CHARM women for eight weeks after delivery for follow-up 

care. After that time, the women receive ongoing care from a community-based obstetrics and 

gynecology clinic or a primary care provider. Women who received buprenorphine from the COGS 

clinic also need to transfer to a new MAT provider. The COGS clinic helps women to find new 

providers and make appointments.

A current challenge for the CHARM Collaborative is finding a new provider who will accept women 

transitioning from the COGS clinic as clients. Vermont’s MAT capacity is limited, and the state 

requires MAT providers to give priority to pregnant women needing MAT. Once a woman has given 

birth, she loses priority access. CHARM women who received MAT from clinics other than COGS can 

usually continue doing so without changing their provider after the neonatal period.

Involvement of Child Welfare System and Courts

VDCF does not contact CHARM families who are stable and providing safe care for their infant. If 

safety concerns are reported to VDCF about a CHARM family, the department conducts safety 

assessments, opens child welfare cases for these families when appropriate, and creates treatment 

plans, using the same protocols it uses for families not enrolled in CHARM.

CHARM families have more contact with more providers than typical VDCF families. As a result, 

providers serving CHARM families and the CHARM Collaborative team give VDCF more information 

about CHARM families than is typically available for non-CHARM families on which to base case 

planning and permanency decisions. Court proceedings for CHARM families, when needed, also 

follow standard practices. Judges benefit from having more complete information on women 

involved with CHARM, as it is more than they typically receive on women not involved with CHARM.
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E. Elements of System 

Linkages

An intensive collaborative effort like 

CHARM is necessary to address the 

complex needs of women with opioid 

use disorders during pregnancy and 

their families. Developing a successful 

and sustainable collaborative requires 

commitment from multiple agencies 

and a coordinated multiyear effort. The 

CHARM Collaborative is an example 

of a highly successful collaborative 

that has developed and implemented 

multiple elements of system linkages. 

The practice elements of screening and 

assessment, engagement and retention 

in care, services to infants, and collaboration with related agencies are described throughout this report.

The CHARM Collaborative also implemented some of the other 10 elements of system linkages 

described earlier in this report, including the underlying values and principles of collaboration, 

joint accountability and shared outcomes, information sharing and data systems, budgeting and 

program sustainability, and training and staff development. This section discusses the importance 

of each of these elements and how the CHARM Collaborative has addressed them. More 

information on establishing successful collaborative efforts and technical assistance is available 

through the publication Screening and Assessment for Family Engagement, Retention, and Recovery 

(SAFERR) from the National Center on Substance Abuse and Child Welfare.

Collaborative Practice Tool

The Screening and Assessment for Family 

Engagement, Retention, and Recovery is a 

collaborative model to help child welfare, 

substance abuse treatment, and family court 

professionals make better-informed decisions 

for children and families affected by substance 

use disorders: http://store.samhsa.gov/

product/Screening-and-Assessment-for-FamilyEngagement-Retention-and-Recovery-SAFERR-/

SMA08-4261.

Underlying Values and Principles of Collaboration

CHARM Collaborative members have gained an understanding of the missions and mandates of 

each partner agency. The values and principles that guide their collaborative efforts are reflected in 

their MOU (see Attachment A: CHARM Collaborative Memorandum of Understanding) and articulated 

in presentations and training programs provided by members. These values include the common 

goal of a healthy family, recognition that the formal charge of the collaborative is to ensure child 

safety, and a commitment to comprehensively support families and ensure the safety of their 

children.

An important principle of the CHARM Collaborative is acceptance of disagreement without 

disrupting the process or relationships among members. The group usually agrees on 

recommendations regarding whether a child will remain at or be removed from the home. 

However, when one or more members disagree with a group decision about removal of a child, 

they use an agreed upon process for expressing their dissenting views. According to this process, 

the disagreement is made known to the group, and the members can write their opinion in a letter 

to the judge, which becomes part of the family’s case file. When CHARM Collaborative members 

disagree about the need to open a VDCF case, the process is different. The group recognizes that 

VDCF operates independently from the CHARM Collaborative and is ultimately responsible for child 

safety. When VDCF representatives decide to open a case based on information shared at a CHARM 

Collaborative meeting, they inform collaborative members. In the past, VDCF representatives 

did not always share their decisions with the CHARM Collaborative, a practice that damaged 
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Appendix 5: CHARM Collaborative Case Study

trust among CHARM Collaborative members. 

Agreement about how to communicate differing 

views on significant decisions has enhanced 

the trust and effectiveness of the CHARM 

Collaborative.

Joint Accountability and Shared Outcomes

Each CHARM provider monitors and reports the 

results of outcome measures within his or her 

agency or institution, but most do not analyze 

or report data on the subset of women that their 

agency or institution serves who are enrolled in 

CHARM. Members share information on outcomes 

that are relevant to other members of the CHARM 

Collaborative.

At present, the CHARM Collaborative has no 

mechanism for consistently monitoring shared 

outcome measures. If this group is able to 

identify and monitor shared outcomes in the 

future, its members might be in a better position 

to quantify their effectiveness; identify areas 

that need improvement; and communicate with 

stakeholders about the ability of the collaborative to achieve efficiencies, save money, or prevent 

costs. Shared outcome measures for a group like the CHARM Collaborative could include indicators 

of child well-being and safety, infant health and development, and parental engagement in 

treatment and maintenance of recovery.

Examples of relevant outcome measures come from a study led by a COGs obstetrician (Meyer, 

et. al., 2012). This study found that increased access to MAT for pregnant women improved infant 

health outcomes and allowed more infants to remain with their mothers.

“As we [VDCF] learned more about 

medication-assisted treatment, 

about all the support these women 

were getting, like case management 

through the visiting nurses 

association, medical follow-up, 

and medication management, and 

about the benefits of all this support 

to the child, it led to a shift in our 

thinking. Understanding that the 

CHARM Collaborative provided a 

comprehensive approach and these 

women were pretty well monitored 

helped me feel comfortable that 

child safety was being attended to.”

- CHARM Collaborative member

Information Sharing and Data Systems

Shared information is a prerequisite for joint accountability. Joint information systems form 

the basis for communicating across systems and are necessary to track progress toward shared 

goals. Effective communication and information sharing provide the guideposts to gauge the 

effectiveness of the programs in the CHARM Collaborative.

The ubiquity of electronic medical records provides communities that are developing a new 

collaborative with more opportunities to create secure information sharing systems than the 

CHARM Collaborative founders had a decade ago. Groups can determine early in their development 

which information each partner needs and when. Establishing a secure and efficient mechanism 

to share, monitor, and protect client information then becomes possible. A formal MOU and/or 

information-sharing agreement signed by all members is necessary for effective and appropriate 

exchange of client information.

CHARM Collaborative members share information on clients who have signed a comprehensive 

release-of-information form. For clients who have not signed the form, collaborative members 

share information as an empaneled child protection team in compliance with state statute. The 

release-of-information authorization allows collaborative members to discuss the needs of each 

family during their monthly meetings and to exchange health and safety information in between 
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Appendix 5: CHARM Collaborative Case Study

meetings. Collaborative members do not share any data electronically because not all members 

can do so securely. The facilitator records the information that collaborative members share and 

the decisions members make during their monthly meetings, and members receive paper copies 

of these notes at the next meeting. The facilitator also shares paper copies of the list of families to 

be discussed each month at the beginning of each meeting. Each CHARM Collaborative member 

follows his or her agency’s protocols to manage and protect the hard-copy information shared 

during meetings.

The MOU and the comprehensive release-of-information form that the CHARM Collaborative 

created effectively address the requirements and restrictions of federal information-sharing 

regulations. Federal regulations governing the protection of patient records concerning alcohol and 

drug abuse (Title 42 of the Code of Federal Regulations, Part 2,5

 and the Health Insurance Portability 

and Accountability Act of 1996) are often seen as barriers to effective information sharing by 

community collaboratives. By working across systems and using the services of legal professionals, 

the CHARM Collaborative was successful in creating protocols and documents that allow members 

to share information in ways that are effective, legally permissible, and respectful of individual 

and family privacy and confidentiality. (See Attachment A: CHARM Collaborative Memorandum of 

Understanding and Attachment B: CHARM Release of Information.)

Budgeting and Program Sustainability

Cost of the Collaborative

Although no cost studies on the impact of the CHARM Collaborative have been conducted, the 

staff providing the case management believe that the model allows them to provide higher quality 

services in less time than would be possible without the collaborative. For example, the program 

avoids costs by coordinating services for 20 or more families in each 2-hour monthly CHARM 

Collaborative meeting. Without these monthly meetings, coordinating services for each family 

would take 15 minutes to several hours each month, so the total case management time required 

for all of these families would be much greater than two hours. Based on a rough estimate of one 

hour of coordination time per family per month, the CHARM Collaborative saves 18 staff hours per 

month. A cost analysis is needed to determine the actual costs of the CHARM Collaborative and 

how much money it avoids or saves.

About 15 professionals attend each monthly CHARM Collaborative meeting, for a total of 30 staff 

hours. With the exception of the facilitator, agencies contribute the time of each member to attend 

the meetings in kind. Some agencies bill the time to third-party payers as case management or 

case coordination. Others categorize the time as an administrative cost. All participating agencies 

believe that attendance at these meetings is a cost-effective use of staff time.

Funding for Services

Most CHARM women are eligible for Medicaid during pregnancy. Medicaid covers prenatal care 

through labor and delivery and for 60 days postpartum. Medicaid eligibility rules vary by state. 

Most states provide Medicaid benefits to pregnant women, earning up to 185 percent of the federal 

poverty level. Most CHARM women continue to be eligible for Medicaid as long as the baby remains 

in their home. If a child is removed from its mother’s care, Medicaid continues to cover the medical 

costs of the baby but not necessarily those of the mother. Loss of Medicaid coverage results in 

barriers to continued medical care and family planning. In Burlington, women without Medicaid or 

other health insurance coverage can receive medical care from federally qualified health centers.

5

 More information on substance abuse confidentiality regulations is available on the SAMHSA website at 

http://www.samhsa.gov/about-us/who-we-are/laws/confidentiality-regulations-faqs (accessed November 13, 2015)
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Appendix 5: CHARM Collaborative Case Study

Funding for MAT and substance abuse treatment services in Vermont has recently changed. In 

January 2014, the State of Vermont implemented the Hub and Spoke initiative, a new system for the 

integrated treatment of substance use disorders. The “hubs” are five regional specialty treatment 

centers, and the “spokes” are more than 150 physician offices around the state, including primary 

care providers, obstetricians and gynecologists, outpatient substance use treatment providers, 

and federally qualified health centers. Hubs provide comprehensive assessments and treatment 

protocols, methadone treatment and supports, initiation of buprenorphine, care coordination 

and referrals for ongoing care, consultation to physician offices (spokes), and ongoing care for 

clinically complex patients. The hubs are funded by the state’s Division of Alcohol and Drug Abuse 

Programs and they provide buprenorphine prescriptions, administration, and monitoring; substance 

use disorder treatment services, including counseling, contingency management, and access to 

recovery support; and care coordination. The spokes receive funding from the Vermont Department 

of Health Access on a fee-for-service basis.

Two CHARM partners are directly involved in the Hub and Spoke initiative. The Howard Center, where 

many CHARM women receive MAT and substance use disorder treatment, is a designated hub. The 

COGS clinic, where many CHARM women receive prenatal care and MAT (buprenorphine only), also is 

a designated spoke. Additional details on the Hub and Spoke initiative are provided in Attachment C: 

Hub and Spoke Initiative.

Sustainability

Staff from member organizations participate in the CHARM Collaborative on an in-kind basis. The 

only exception is the facilitator from KidSafe. A combination of funding from the state and small 

local grants supports her role in the CHARM Collaborative. The amount and source of these funds 

vary from year to year.

Training and Staff Development

Cross-training for CHARM Collaborative staff members is essential at all levels—administrative, 

management, and line level—to ensure cooperation between key players in the systems. Training 

needs to be ongoing, and a combination of formal and informal training opportunities works well.

When the CHARM Collaborative began, members provided formal and informal cross-system 

training for each other as they discussed each family. Founding members of CHARM also attended 

conferences to broaden their knowledge of practices within their respective fields and across 

disciplines. CHARM Collaborative members continue to participate in cross-training, typically in 

the form of 15- to 30-minute sessions before the regular monthly meetings. Training topics are 

driven by the needs of the group. For example, after an infant death, the state medical examiner 

gave a presentation to the CHARM Collaborative on the process of investigating a child’s death, 

and the Department for Children and Families provided CHARM members with training about the 

requirements for reporting prenatal substance exposure. In addition, ICON annual conferences on 

care for infants with prenatal opioid exposure are open to all CHARM members. These conferences 

typically address prevention and best practices for treatment of NAS as well as new research findings 

on the long-term impact of prenatal exposure to opioids.

F. Summary

Over a 16-year period, the extraordinary commitment of the CHARM Collaborative to a crosssystem approach in working with pregnant women with opioid use disorders and their infants 

has resulted in improvements in practice and better outcomes for clients. The initiative has made 

possible the provision of a full range of services to families in half of the State of Vermont. The full 

service array will become available to more families as additional communities replicate the model. 

The quality of care of these services has improved through collaborative practice, with pregnant 
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Appendix 5: CHARM Collaborative Case Study

women gaining access to MAT and additional services earlier in their pregnancies. At the client 

level, outcomes have included healthier pregnancies, healthier children, and a greater likelihood 

that families will remain together or be reunified safely. The lessons learned from the CHARM 

Collaborative about overcoming barriers to collaborative practice can guide other communities 

seeking to help pregnant women with opioid use disorders.

References

Borden, S. (2013). Policy Considerations and Collaborative Partnerships: Working with Opioid Department 

Pregnant Women. Presented at the American Association for the Treatment of Opioid Dependence 

(AATOD) Conference. November 9-13, 2013. Philadelphia, PA.

Children and Family Futures. (2011). The collaborative practice model for family recovery, safety and 

stability. Irvine, CA: Author. Retrieved from http://www.cffutures.org/files/PracticeModel.pdf

(accessed August 19, 2015).

Finnegan, L. P., Connaughton, J. F. Jr., Kron, R. E., & Emich, J. P. (1975). Neonatal abstinence syndrome: 

Assessment and management. Addictive Diseases, 2, 141–158.

Meyer, M., Benvenuto, A., Howard, D., Johnston, A., Plante, D., Metayer, J., & Mandell, T. (2012). 

Development of a substance abuse program for opioid-dependent nonurban pregnant women improves 

outcome. Journal of Addiction Medicine, 6, 124–130.

Vermont Department of Children and Families. (2011). Family services policy manual, Child Safety, 

Screening Reports of Child Abuse and Neglect, 51. Montpelier, VT: Author. Retrieved from http://dcf.

vermont.gov/sites/dcf/files/FSD/Policies/51.pdf (accessed March 9, 2016).

Young, N. K., Gardner, S., Otero, C., Dennis, K., Chang, R., Earle, K., & Amatetti, S. (2009). Substanceexposed infants: State responses to the problem. (HHS Publication No. SMA 09-4369). Rockville, MD: 

Substance Abuse and Mental Health Services Administration. Retrieved from https://www.ncsacw.

samhsa.gov/files/Substance-Exposed-Infants.pdf (accessed August 19, 2015).
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Attachment A: CHARM Collaborative Memorandum of Understanding

Attachment A: CHARM Collaborative Memorandum

of Understanding

This Memorandum of Understanding is effective immediately following obtainment of the final 

signature of the parties listed on Attachment A [hereinafter referred to collectively as the “Parties,” or 

for any one of the Parties, as a “Party”] but no later than the first day of December 2012 excluding any 

unsigned Parties.

Whereas, the Children and Recovering Mothers Program [hereinafter “CHARM” or the “Program”] is a 

coalition of service providers serving women with chemical dependency and their children. It is not 

a separate legal entity.

Whereas, the purposes of CHARM are to coordinate services to meet the needs of pregnant and 

parenting women with chemical dependency and their children, improve the delivery of services 

to these women and their children, and identify gaps in services that need to be addressed.

Whereas, an individual participating in CHARM [hereinafter “client participant”] may be provided 

direct services by any or all of the Parties, in which case that individual becomes a client of each Party 

that provides such a service.

Whereas, the Parties desire to set forth their understandings with respect to the way in which they 

will comply with the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 

[hereinafter “HIPAA”], federal confidentiality provisions governing substance abuse treatment, and 

State confidentiality provisions.

Now, therefore, the Parties, acting by and through the undersigned duly authorized agents, hereby 

agree as follows:

(1) With respect to all information related to client participants in the Program, each Party agrees to 

fully abide by the terms and conditions set out in HIPAA, 42 C.F.R. Part 2, 7 C.F.R. § 246.26, and state 

confidentiality provisions.

(2) Each Party that is currently subject to HIPAA will continue its practice of being individually 

responsible for providing HIPAA Privacy Rule protections (including, without limitation, a Notice 

of Privacy Practices) and state privacy protections to each client participant to whom it provides 

direct services.

(3) In order to facilitate the internal case coordination, referral and assessment needs of client 

participants, each such participant in the Program will be requested to sign a Client Consent for 

release and sharing of information among the Parties in the form attached to this Memorandum 

of Understanding as Attachment B (hereinafter the “Client Consent”). The Client Consent, when 

signed by the client participant, is intended solely for the uses described in it and is not intended 

to serve as a consent for release of information with respect to any other matter, including, 

without limitation, treatment, payment, or health care operations, or for disclosure of confidential 

information to any third party, except as expressly so authorized by that Client Consent.

(4) Except as otherwise required by state or federal law, each Party specifically agrees to restrict 

access to and use of any and all information regarding client participants only to those personnel 

who require access to such information for the purposes set forth in the Client Consent.

(5) The Parties further agree that, unless otherwise provided by law, any and all information 

regarding client participants shall not be used or disclosed for any purpose except those specified in 

the Client Consent.
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Attachment A: CHARM Collaborative Memorandum of Understanding

(6) The Parties recognize that as mandated reporters of suspected child abuse and neglect under 

the provisions of 33 V.S.A. § 4913, they are required to report any and all incidences where there 

is reasonable cause to believe that a child has been abused or neglected or is at significant risk of 

harm to the Family Services Division of the Vermont Department for Children and Families.

(7) This Memorandum of Understanding inures to the benefit of and is binding on the Parties 

and is intended for the sole and exclusive benefit of the Parties. Nothing in this Memorandum of 

Understanding shall give rise to or be deemed to give rise to any third party beneficiary rights to 

any third party, and in particular, but without limitation, this Memorandum of Understanding does 

not give rise to any third party rights to any client participant.

So entered into by,

Fletcher Allen Health Care

By __________________________________

Duly Authorized Agent

Date _________________________________

Howard Center for Human Services, Inc.

By __________________________________

Duly Authorized Agent

Date _________________________________

KidSafe Collaborative, Inc.

By __________________________________

Duly Authorized Agent

Date _________________________________

Lund Family Center

By __________________________________

Duly Authorized Agent

Date _________________________________

Vermont Department for Children and Families

By __________________________________

Duly Authorized Agent

Date _________________________________

Vermont Department of Corrections

By __________________________________

Duly Authorized Agent

Date _________________________________
105

Attachment A: CHARM Collaborative Memorandum of Understanding

Vermont Department of Health

By __________________________________

Duly Authorized Agent

Date _________________________________

Visiting Nurse Association, Inc.

By __________________________________

Duly Authorized Agent

Date _________________________________

Franklin County Home Health Agency, Inc.

By __________________________________

Duly Authorized Agent

Date _________________________________

Northwestern Medical Center, Inc.

By __________________________________

Duly Authorized Agent

Date _________________________________

Northwest Counseling and Support Services, Inc.

By __________________________________

Duly Authorized Agent

Date _________________________________

Department of Vermont Health Access

By __________________________________

Duly Authorized Agent

Date _________________________________

Vermont Agency of Human Services, Field 

Services Division

By __________________________________

Duly Authorized Agent

Date _________________________________
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Attachment A: CHARM Collaborative Memorandum of Understanding

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Attachment B: CHARM Collaborative Release of Information

Attachment B: CHARM Collaborative Release of 

Information

CHILDREN AND RECOVERING MOTHERS (CHARM) PROGRAM

CONSENT TO USE AND DISCLOSURE OF HEALTH INFORMATION

FOR TREATMENT AND SOCIAL SERVICES

I, ____________________________________________, date of birth _________________________ , 

authorize the use and disclosure of my health and treatment information by and among each of the 

team members of the Children and Recovering Mothers (CHARM) Team, including any individual(s) 

involved in the direct service or service coordination within each organization. The Children and 

Recovering Mothers (CHARM) Team members participate from the following organizations:

§ Fletcher Allen Health Care

§ Northwestern Medical Center

§ Visiting Nurse Association, Inc.

§ Franklin County Home Health Agency, Inc.

§ Lund Family Center

§ Northwest Counseling and Support Services, Inc.

§ Howard Center (including the Chittenden Clinic and Rocking Horse Program)

§ KidSafe Collaborative

§ Vermont Agency of Human Services: Department of Health, Department for Children and 

Families (including Children’s Integrated Services), Department of Corrections, Department of 

Vermont Health Access, and Agency of Human Services Field Services Division

The means of this use of disclosure may be written, verbal or electronic.

I understand that the purposes of the CHARM Team are to evaluate the need for and facilitate the 

coordination of medical services, substance abuse treatment services, and social support services 

in order to best provide for the safety of my child and to support my successful treatment during 

pregnancy and post-partum.

I authorize the use and disclosure of my health and treatment information and that of my child by 

and among the participating organizations of the Children and Recovering Mothers (CHARM) Team 

solely for these stated purposes.

The health and treatment information that will be shared may include the following:
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Attachment B: CHARM Collaborative Release of Information

§ Name, date of birth

§ Address, phone number(s)

§ Antenatal and post-partum medical care and treatment provided to me and my child(ren)

§ Pregnancy and delivery

§ Psycho-social history

§ Current living situation

§ History and attendance at alcohol/drug treatment, including methadone maintenance, and 

mental health services

§ Lab test results, including drug testing

§ Mental health and/or drug and alcohol assessment, diagnosis, treatment, progress and discharge 

summary (if applicable)

§ Children’s health and safety assessments

§ WIC program participation history

§ Department for Children and Families history of involvement

§ Criminal history and/or current involvement with Department of Corrections

§ Other (specify) ___________________________________________________________________ .

 ADDITIONAL PROVISIONS CONCERNING YOUR CONSENT:

I understand that my alcohol and/or drug treatment records are protected under federal statutes 

and regulations governing the Confidentiality of Alcohol and Drug Abuse Patient Records, including 

42 C.F.R. Part 2, and my personal health information is protected by the Health Insurance Portability 

and Accountability Act of 1996 [“HIPAA”], 45 C.F.R. Pts. 160 & 164, and in some cases by 7 C.F.R. § 

246.26, and such information cannot be disclosed without my written consent unless otherwise 

provided for in these provisions.

I also understand that my decision to use the services of the Children and Recovering Mothers 

(CHARM) Team is voluntary. My signature indicates that I understand the important information 

provided in this Consent. I may end CHARM Team services at any time.

I understand that if I want members of the CHARM Team to disclose information about me or 

my child to someone other than the members of the CHARM Team, I will need to sign a separate 

Consent or Authorization to release such health and treatment information for each party to whom 

such information is disclosed, except as specifically described below.

I further understand that if any of the members of the CHARM Team or the participating 

organizations want to use or disclose any information regarding me or my child for a purpose 

other than that described in this Consent form, except information required by law pertaining 

to the mandatory reporting of suspected child abuse or neglect, that member or participating 

organization must obtain my written permission, stating the purpose of the consent, prior to using 

or disclosing that information.

I also understand that I may request restrictions on the use or disclosure of treatment records. 

I understand that the CHARM Team will consider my request but is not bound to agree to it in 
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Attachment B: CHARM Collaborative Release of Information

which case I may decline to participate with the CHARM Team. However, my refusal to be 

involved with the CHARM Team will not affect my ability to receive services from the individual 

participating organizations.

I further understand that generally the participating organizations may not condition my treatment 

with them on whether I sign a consent form, but that in certain limited circumstances, I may be 

denied treatment with them if I do not sign such a form.

 I may revoke this Consent at any time by notifying any member of the Children and Recovering 

Mothers (CHARM) Team, but revoking this Consent will not affect any actions that were taken by the 

CHARM Team or its participating organizations before I revoked it.

 This Consent will remain in effect for the period while I receive services and for thirty (30) days after 

the termination of services by the last participating organization on the CHARM Team providing 

services to me unless I choose to terminate it on the following date, or as a result of the following 

event or condition: __________________________________________________________________ .

I understand that the Vermont Department for Children and Families [DCF] may currently have 

opened, or in the future may open, a child protection case that involves me or my child. If so, I 

specifically authorize the DCF representative on the CHARM Team to disclose and/or re-disclose 

health and treatment information about me: (1) to other employees of DCF who have a need to 

know such information; and (2) to the Vermont Family Court and any party to a juvenile proceeding 

which involves me or my child brought under Chapters 51–53 of Title 33 of the Vermont Statutes.

 I have read all of the above information, and I understand its contents and consent to the 

disclosure and/or re-disclosure of the confidential information identified above to the participating 

organizations and staff members of the CHARM Team for the purposes specified.

___________________________________________________________ _______________________

Name of Patient (Please Print) Date

___________________________________________________________ _______________________

Signature of Patient (18 and over or Emancipated Minor) Date

or Signature of Parent/Guardian or Legal Representative

___________________________________________________________ _______________________

Witness: Name and Title Date

This Consent to Release Information will be kept 

on file by the KidSafe Collaborative (Community 

Network for Children, Youth and Families, Inc.) or 

by another authorized organization on behalf of 

the CHARM team, unless revoked by the client or 

terminated as specified in this agreement.

Rev.: Date: _______________
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Attachment B: CHARM Collaborative Release of Information

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Attachment C: Hub and Spoke Initiative

Attachment C: Hub and Spoke Initiative

 
112

Attachment C: Hub and Spoke Initiative

 
113

Attachment C: Hub and Spoke Initiative

 
114

Attachment C: Hub and Spoke Initiative

 
115

Appendix 6: Additional Acknowledgments

Appendix 6: Additional Acknowledgments

The authors acknowledge the following health care, addiction treatment, child welfare, court, 

and other professionals who served on the National Working Group on Addressing Pregnant 

and Parenting Women with Opioid Use Disorder, Medication-Assisted Treatment, and Neonatal 

Abstinence Syndrome for their invaluable contributions to the development of these guidelines.

Diane J. Abatemarco, Ph.D.

Thomas Jefferson University/Nemours 

Children’s Health System

Kim Bishop-Stevens, M.S.W.

Massachusetts Department of Children 

and Families

Mark Brown, M.D.

Eastern Maine Medical Center

Sharon Burke, M.D.

Children’s Specialized Hospital

Stanley Carmical, J.D.

District Court, State of North Carolina

Stacy Chamberlain, M.A.

Kansas Department for Aging and Disability 

Services/Behavioral Health Services

Penny Clodfelter, M.S.W.

Jackson County Family Drug Court

Lori Criss, M.S.W.

The Ohio Council of Behavioral Health & Family 

Services Providers

Sharon Dembinski, M.S.N.

Methadone Support Organization

Jeremy Dubin, D.O.

Healing Arts Family Medicine

Jason Fields, M.D.

Drug Abuse and Comprehensive 

Coordinating Office

Norma Finkelstein, Ph.D.

Institute for Health and Recovery

Connie Gardner, B.S.W.

Tennessee Department of Children’s Services

Balaji Govindaswami, M.B.B.S., M.P.H.

Santa Clara Valley Medical Center

Sherri Green, Ph.D.

University of North Carolina at Chapel Hill

Marc Hering, M.A.

Center Point, Inc.

Denise Holden, M.H.S.

RASE Project

Lauren Jansson, M.D.

Johns Hopkins University School of Medicine

Hendree Jones, Ph.D.

University of North Carolina at Chapel Hill

Rebecca Jones-Munger, C.N.M., M.P.H.

Sonoma County Department of Health Services

Karol Kaltenbach, Ph.D.

Sidney Kimmel Medical College (Jefferson 

Medical College), Thomas Jefferson University

Rebecca Kelly-Cardona, M.S.

Helen Ross McNabb Center

Linda Mann, C.A.P., L.C.S.W.

Drug Abuse and Comprehensive 

Coordinating Office

Judith Martin, M.D.

Department of Public Health, 

City and County of San Francisco
116

Appendix 6: Additional Acknowledgments

Marjorie Meyer, M.D.

University of Vermont

Mark Moran, M.S.W.

Eastern Maine Medical Center

Linda Radigan, M.Ed.

Office of Community Services, Tennessee 

Department of Children’s Services

Julia Roguski, M.A.

Savio House

Chuck Roper, Ph.D.

Travis County Health & Human Services 

Christine Scalise, M.A.

New Jersey Division of Mental Health and 

Addiction Services

Carl Seashore, M.D.

University of North Carolina School of Medicine

Paul Seave, J.D.

Sacramento County Superior Court

Robert Sege, Ph.D.

Boston University

Karen Shea, M.S.W.

Family Services Division, Vermont Department 

for Children and Families

Juanita Stedman, J.D.

Juvenile Court of Cobb County

Christine Swenson-Smith, M.S.W.

Pima County Juvenile Court

Christine Ullstrup, M.S.W.

Meta House

Dirk Weddington, J.D.

Knox County Juvenile Court

Jay Wurscher

Oregon Department of Human Services

The authors also acknowledge the following experts for reviewing these guidelines.

Sally Borden, M.Ed.

KidSafe Collaborative

Melinda Campopiano, M.D.

Center for Substance Abuse Treatment, 

Substance Abuse and Mental Health 

Services Administration

Robert Lubran, M.S., M.P.A.

Center for Substance Abuse Treatment, 

Substance Abuse and Mental Health 

Services Administration

Robert Morrison, M.A.

National Association of State Alcohol and Drug 

Abuse Directors

Robert Newman, M.D.

Baron Edmond De Rothschild Chemical 

Dependency Institute, Beth Israel (Retired)

Lynn Paltrow, J.D.

National Advocates for Pregnant Women

Mark Parrino, M.P.A.

American Association for the Treatment of 

Opioid Dependence, Inc.

Stephen Patrick, M.D.

Vanderbilt University School of Medicine

We also acknowledge the following staff members of the National Center on Substance Abuse and 

Child Welfare for their contributions to the development of this publication: Hanh L. Dao, M.S.W.; 

Jill Gresham, M.A.; Kelly Loo Jones; and Cathleen Otero, M.S.W., M.P.A.
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SMA 16-4978