Resources:

• FPQC MORE Initiative SBIRT Video: Dr Pam Carbiener, FPQC OB OUD expert explains the process for conducting SBIRT including patient interview process.
• Guide to Including SBIRT in OB Visit (NNEPQIN)

Universal Screening

FPQC recommends using one of the following validated screening tools:

• NIDA Quick Screen: Three question online tool.  Validated in patients ≥18 years old.  
• 5P’s Screening Tool & Follow-up Questions:  Designed specifically for pregnant women, this tool asks about substance use by women’s parents, peers, partner, during pregnancy, and in her past.
• CRAFFT: This provider guide for the CRAFFT (a mnemonic acronym for the first letters of key words in the six questions) screening tool offers information on how to use the screen.  The CRAFFT is specifically for use with patients under 21 years of age.

References:

• AIM Opioid Screening Tool Chart: A comparison of 11 screening tools with description, pros and cons, sensitivity/specificity developed by Alliance for Innovation for Maternal Health
• Accuracy of Three Screening Tools for Prenatal Substance Use: This article assesses the accuracy of 4P’s Plus, NIDA Quick Screen-ASSIST (Modified Alcohol, Smoking and Substance Involvement Screening Test), and the SURP-P (Substance Use Risk Profile-Pregnancy) screening tools.  
• AIM Screening Slides:  Discusses SBIRT. Weighs benefits and disadvantages of the following screening tools: 4Ps Plus, Integrated 5P’s, Substance Use Risk Profile – Pregnancy (SURP-P), NIDA Quick Screen, CRAFFT). Also covers Brief Interventions (including motivational interviewing), and Referral to Treatment (MAT, residential treatment, other ambulatory services). Includes state-specific referral resources. 

Secondary Screening

References:

• Opioid Addiction with Medical Co-Morbidities: From Providers Clinical Support System (PCSS). Encourages treatment for substance use to reduce HCV and HIV risk. Discusses how individuals with chronic pain can avoid non-prescribed opioid use through MAT.
• Opioid Addiction with Psychiatric Co-Morbidities: (PCSS). Brief, print-friendly document discussing how adults with mental illness are at higher risk for concomitant drug use.
• ACOG Committee Opinion No. 757: Screening for Perinatal Depression: ACOG. Consensus opinion stating obstetric care providers should screen pregnant women for anxiety and depression. 

Screening Tools:

• Edinburgh Postnatal Depression Scale: Ten short statements to help health professionals in detecting mothers suffering from PPD. Takes approximately five minutes to administer.  
• Depression Screening Tool (WCF): Eight question screening tool adapted from the PHQ9 by Women’s Care Florida
• Intimate PartnerViolence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings: This CDC and National Center for Injury Prevention and Control document compiles existing tools for assessing intimate partner violence and sexual violence victimization in clinical/healthcare settings. Go to pages 22-24 for the Abuse Assessment Screen.

Brief Intervention

FPQC MORE Clinical Pathway Algorithms:

• Prenatal Care
• Delivery Hospital Visit
• Antepartum Hospital Visit

Resources:

• Brief Negotiated Interview. The BNI is in the form of an algorithm that guides providers through the health intervention with carefully phrased key questions and responses, all at the providers’ fingertips. It has foundations in motivational interviewing. 
• FPQC Pocket Card: A script to guide providers as they address substance use disorder in their patient populations. 
• ACOG District II implementing SBIRT (video): An Effective Approach to Care—a video modeling a patient encounter using SBIRT.

• FPQC MORE Initiative POSC Video: Heidi Wright, RN expert on OUD explains the purpose of the POSC and how to assist a pregnant patient with developing her POSC

Safe Discharge Staff Education Modules:

• Safe Plans of Care with Erin Hough
• Supporting Safe Plans of Care with Dixie Morgese

Comprehensive Discharge Planning:

• Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders: Comprehensive document to assist states and communities address the needs of pregnant women with OUD. SAMHSA.
• FPQC MORE Discharge Checklist. Also available as a Word document.
• Child Abuse and Treatment Act (CAPTA): Official congressional language that describes the CAPTA Reauthorization Act of 2010, includes SUD prevention and treatment for patients and communities.
• Florida Healthy Families Plan of Safe Care link to resources: Florida DCF website. Describes Florida’s policy and procedure responses to CAPTA and the Comprehensive Addiction and Recovery Act of 2016 (CARA). Includes several documents on Plans of Safe Care (POSC).
• Comprehensive Addiction and Recovery Act of 2016: Plans of Safe Care Training Video (2/5/19): Twenty minute video on POSC.

POSC Templates:

• Florida Healthy Families Plan of Safe Care document – DCF template: Includes maternal, infant, and family POSC components.
• Plan of Safe Care form – Flagler/Volusia Healthy Start: Sample form.
• Plan of Safe Care Template – District 1: Sample form

• FPQC Mapping Tool for Services
• Examples of Completed Community Mapping Tools:
  • PIN Map
  • Indian River Map
  • Broward Map
• Buprenorphine Providers in FL: Map of buprenorphine providers searchable by city, state, or zip code. SAMHSA
• Opioid Treatment Program Directory: Opioid treatment programs searchable by state. SAMHSA.
• National Treatment Locator: SAMHSA is beta testing a new design for its substance use treatment locator.  This version is searchable by city, zip code, treatment type, payment options, and types of MAT offered.
• Florida Maternal Mental Health Collaborative: Resources for providers, mothers, and fathers on perinatal mental illness. Offers options to search by healthcare need, preferred payment type, and geographic location.
• FL Healthy Start Connect: This one-stop entry point provides phone numbers by county to link pregnant women and families with Healthy Start services.
• DCF’s Substance Abuse and Mental Health webpage: Under the title Find Local Services by county you can click on a drop down menu and select the county of residence. This will take you to a page with resources such as the managing entity, the CAT team, FACT team and mobile response team.
• List of Florida Women and Children Substance Abuse Residential Services  
• Map of Current Sites: Early Childhood Court addresses child welfare cases involving children under the age of three. It is a problem-solving court - where legal, societal, and individual problems intersect. Problem-solving courts seek to address not only the legal issues but also the underlying non-legal issues that will benefit the parties and society as well. The goal of Florida's Early Childhood Court is to improve child safety and well-being, change the experience and outcomes of children in the child welfare system, heal trauma and repair the parent/child relationship, expedite permanency, and stop the intergenerational cycle of abuse/neglect/violence.

MORE:

• Getting Real (Video): Taking the First Steps Toward Recovery to encourage moms to seek care for substance use disorder.
• The MORE Hope Booklet (PDF) developed in collaboration with the Hillsborough Healthy Start Coalition. The booklet provides comprehensive education and guidance to women affected by substance use.
• Patient Education Resources by Topic: An organized table of resources compiled by FPQC staff that may be useful for you to explore patient education resources.
• Infographics: The National Perinatal Association has produced a series of infographics on perinatal substance use that can be downloaded for use by patients and providers.  This site also contains social media infographics that could be used to promote understanding and education on perinatal substance use issues
• Brochure on Opioid Safety & How to Use Naloxone (PDF)

NAS:

• NAS Family Handbook (FPQC, March of Dimes, Healthy Start of Hillsborough, Florida Department of Health)
• Healthy Start Resources - Right From the Start (English and Spanish)
• "Be with your baby: You are the Treatment!" Parent Card (IL)
• "NAS: What You Need to Know" Parent Booklet (IL)

• Provider Education Resources by Topic: Download this chart for a list of staff education resources organized by topic area.
• Buprenorphine Use in Obstetrical Practice (TIPQC & FPQC). In partnership with Tennessee Initiative for Perinatal Quality Care, FPQC is offering this free CME training. The first session describes the basics of Buprenorphine treatment during pregnancy. The second session describes how to make prescribing Buprenorphine in your obstetrical practice work. 
• "What Every OB Provider Needs to Know to Save a Mother's Life" Poster (FPQC)
• "Do You Know? Opioid Use Disorder in Florida: You Can Save a Mother's Life" Poster (FPQC)
• Florida BH IMPACT Program: An innovative initiative by the Florida Department of Health (DOH), the Florida State University (FSU) College of Medicine and the Florida Maternal Mental Health Collaborative (FLMMHC). It includes FREE psychiatric consultations, community referrals, and on-demand responses to mental health questions for prenatal care providers.
• Narcan - Provider Info (ILPQC)
• Pediatric Transitions in Care for the Mother-Infant Dyad Affected by Opioid Use Disorder: ACOG and AAP webinar. This session features pediatric experts in the field as they shared strategies to optimize postpartum transitions in care for the mother-infant dyad.
• Trends in Investigative Practice-Substance Exposed Newborns: DCF Practice Considerations with information about drug testing (examples of how appropriate drug use versus misuse is determined), onset of withdrawal, signs of NAS, substance abuse indicators, and Plan of Safe Care (POSC) components.
• Infographics: The National Perinatal Association has produced a series of infographics on perinatal substance use that can be downloaded for use by patients and providers.  This site also contains social media infographics that could be used to promote understanding and education on perinatal substance use issues.

• Stigma directly fuels the addiction epidemic: This flyer encourages the use of person-first language, including words to use, and words to avoid. 
• “Say This/Not That”: A poster demonstrating non-stigmatizing language to use when discussing substance use disorder.
• From Judgement to Healing: The Impact of Stigma: Learn how to provide less biased support to mothers with substance use disorder. 
• The Power of Perceptions and Understanding: Changing How We Deliver Treatment and Recovery Services. This four-part webcast series educates healthcare professionals about the importance of using approaches that are free of discriminatory attitudes and behaviors in treating individuals with substance use disorders (SUDs) and related conditions, as well as patients living their lives in recovery.
• Beyond Labels: This March of Dimes toolkit is designed to raise awareness about stigma and provides some sample language, stories about stigma from women and healthcare providers, and a very nice list of resources on bias and stigma.
• Stigma and OUD [Opioid Use Disorder]: This course from the Providers Clinical Support System (PCSS) is led by Nurse Practitioner Vanessa Loukas, a PCCS clinical expert. She discusses the issue of stigma in treating patients with opioid use disorder—from the patients to the providers who treat them. 
• Reversing the Stigma of Opioid Addiction: This short video addresses stigma related to drug use in pregnancy –produced by NBC Left Field. 
• Stigma and OUD: What Pediatricians Need to Know in Caring for Mothers and Children: AAP Webinar. This session offers an overview of how stigma related to prenatal opioid use adversely affects the health outcomes for the mother-infant dyad. Faculty present strategies within clinical setting on approaching women of reproductive age about their health history and opioid use outside the context of legal implications.

• "Ask Yourself: Am I Providing Trauma-Informed Care?" flyer (FPQC)
• Trauma-Informed Care inBehavioral Health Services brochure (SAMHSA)
• Health Equity and Social Justice Using a Trauma-Informed Lens, presentation by Annie Lewis-O'Connor
• Working through Trauma to have a Positive Birth Experience, podcast by Justine Leach
• ACOG Committee Opinion 825. Clinical Guidance: Caring for Patients who Have Experienced Trauma 

Trauma-Informed Care Staff Education Modules with Heather Howard:

• Introduction to Trauma-Informed Care (18 min)
• Pregnancy and Trauma-Informed Care (15 min)
• Tips on Providing Trauma-Informed Care to Women with Substance Use Disorder (15 min)

The Nature of Addiction Staff Education Modules

• Physical Addiction Part 1 (12 min)
• Physical Addiction Part 2 (12 min) with Jason Hunt
• Psychological Addiction with Jason Hunt (24 min)
• Treatment Options for Pregnant Women with Substance Use Disorder with Jason Fields (24 min)

Motivational Interviewing Staff Education Modules with Heather Flynn

• Introduction to MI and Evidence for its Use with Women with Substance Use Disorder (20 min)
• Tips on Using Motivational Interviewing in Women with Substance Use Disorder (27 min)

Collaborative approach to treatment of pregnant women with opioid use disorders: This manual offers best practices to states, tribes, and local communities on collaborative treatment approaches for pregnant women living with opioid use disorders, and the risks and benefits associated with medication-assisted treatment.

Staff Education Modules:

• NAS Signs with Brenda Bugbee (12 min)
• Scoring Systems for NAS and Importance of Inter-rater Reliability with Karen Fugate (16 min)
• Non-Pharmacologic Treatment Techniques with Denise Maguire (10 min)
• Non-Pharmacologic Treatment Techniques Demonstrated with Diane Allen (12 min)

• Clinical guidance for treating pregnant and parenting women with OUD and their infants: This Clinical Guide provides comprehensive, national guidance for optimal management of pregnant and parenting women with opioid use disorder and their infants. The Clinical Guide helps healthcare professionals and patients determine the most clinically appropriate action for a particular situation and informs individualized treatment decisions. SAMHSA
• Obstetric Care for Women with Opioid Use Disorder Patient Safety Bundle: The Alliance for Innovation on Maternal Health (AIM) is a national data-driven maternal safety and quality improvement initiative to eliminate preventable maternal mortality and severe morbidity across the United States. This maternal safety bundle addresses readiness, recognition & prevention, response, and reporting & systems learning related to obstetric care for women with OUD.
• Maternal Opioid Use Disorder Toolkit (Massachusetts PQC)
• Example OB Substance Use Disorder Order Set added to established antepartum, labor and postpartum orders (Halifax Health)

• Breastfeeding Recommendations for Women Who Receive Medication- Assisted Treatment for Opioid Use Disorders: AWHONN Practice Brief Number 4: AWHONN’s recommendation promoting breastfeeding for women who receive MAT for OUD.    
• Rooming-In to Treat Neonatal Abstinence Syndrome: Improved Family-Centered Care at Lower Cost: Rooming-in with family and decreased use of NICU beds contributes to reduced pharmacologic therapy, length of stay, and hospital costs for infants with NAS.    
• Association of Rooming-in With Outcomes for Neonatal Abstinence Syndrome: A Systematic Review and Meta-analysis: Robust review of the literature and quantitative meta-analysis of several studies on rooming-in for opioid-exposed newborns. Recommends rooming-in as a best practice for NAS. 

• Toolkit for Perinatal Care of Women with Substance Abuse Disorders (NNEPQIN): This toolkit was developed by a multidisciplinary group of obstetric, pediatric, neonatal, and addiction treatment providers and nurses to assist front-line perinatal care providers to improve the quality and safety of care provided to pregnant women with opioid use disorders in northern New England.
• Mothers and Newborns Affected by Opioids – OB Toolkit and Resources (ILPQC): In 2018 ILPQC worked with hospital teams to implement system changes such as implementation of screening, treatment algorithms, checklists and local resource mapping, as well as clinical culture change using OB provider education, debriefs of OUD cases to identify missed opportunities to improve care, and regular data review to reduce risk and improve outcomes for every pregnant or postpartum woman with OUD.
• Addiction Free CA: A California MAT Expansion Website: The resource library is intended to support a wide variety of stakeholders with information about substance use disorder treatment and prevention

MORE Hospital Folders were sent to our hospital teams and are intended to be given to patients who screen positive for OUD. Learn more about how to implement the MORE Folder from this quick snippet featuring MORE Nurse Consultant Margie Boyer!

We recommend all folders contain the following items:

• Letter of Support from the MORE Medical Lead
• Helping Our Parents Excel (MORE HOPE) Booklet
• MORE Stickers
• Naloxone patient education brochure: Opioid Safety
• Narcan Provider Info page (ILPQC)
• ACOG Committee Opinion #807: Tobacco and Nicotine Cessation During Pregnancy
• MORE SBIRT Pocket Card
• Postpartum LARCs: Are You Ready?
• Trauma-Informed Care Flyer 
• Florida Behavioral Health Impact Flyer

Additional items recommended for the MORE Hospital Folder:

• MORE Checklist Workflow 
• MORE Delivery Hospital Visit Algorithm 
• Narcan 30-60-90 Day Plan 

Additional items recommended for the MORE Community Provider Screening and Resources Folder/Binder:

• MORE Prenatal Checklist 
• MORE Prenatal Visit Algorithm
• MORE Additional Prenatal Resources