Hendree E. Jones

Despite well‐documented harms of prenatal alcohol exposure, evidence‐based treatment guidelines for alcohol use disorder (AUD) during pregnancy remain limited. We systematically reviewed international clinical practice guidelines to examine how they address the full cascade of AUD care during pregnancy, including diagnosis, engagement, treatment initiation, and retention. We searched over 40 clinical practice guideline databases (including PubMed and Guidelines International Network) and gray literature sources globally, identifying 1045 records. Using the Population, Interventions, Comparators, Attributes, Recommendation Characteristics (PICAR) framework, we evaluated guidelines from medical organizations in English‐speaking nations addressing alcohol use and AUD management in pregnancy. Our final analysis included 18 guidelines from the United States, Canada, the United Kingdom, Australia/New Zealand, and the World Health Organization published from 2014 to the present. Two reviewers independently assessed each guideline using the Appraisal of Guidelines Research and Evaluation‐Recommendations Excellence (AGREE‐REX) framework to evaluate quality and risk of bias. We used narrative synthesis to summarize findings across key concepts and care cascade stages. Nearly all guidelines (94%) described risks of alcohol exposure and recommended counseling on cessation (89%), yet few extended beyond these early cascade stages. Only 44% mentioned medications for AUD (MAUD), and merely 17% discussed specific psychosocial treatments. Among guidelines addressing MAUD, only one cautiously supported use, while three explicitly recommended against it. Most guidelines (61%) ended treatment recommendations at referral to specialty care, with half limiting guidance to acute alcohol withdrawal management. Taken together, our findings reveal a stark misalignment between screening emphasis and treatment guidance. While guidelines consistently recommend universal screening and brief intervention, they provide minimal actionable frameworks for managing AUD throughout pregnancy. This gap leaves clinicians without evidence‐based pathways for comprehensive AUD treatment during the prenatal period, highlighting an urgent need to strengthen both the evidence base and clinical guidance for AUD management in pregnancy.

Women with substance use disorders (SUDs) released from incarceration face a markedly elevated risk of fatal overdose during the first 2 weeks post-release compared with women with SUDs in the community. Prior research estimates that individuals leaving incarceration may be more than 100 times more likely to die from overdose during this period than the general population. This article describes a gender-responsive behavioral health reentry model, Engaging and Motivating to Prevent Overdose among Women via Effective Reentry (EMPOWER), implemented statewide in North Carolina. Among 359 self-referred women with SUDs, the program reported zero fatal overdoses during the 2-week post-release period. EMPOWER builds upon Jenna’s Project: Preventing Overdose and Improving Recovery Outcomes for Women Leaving Incarcerated Settings During Pregnancy and Postpartum Periods , which served 132 perinatal women and reported zero fatal opioid overdoses at 6 months post-release. EMPOWER expanded the population to include women aged 18–44 years with a history of illicit substance use across three state prisons, regardless of pregnancy status. These findings suggest that evidence-based behavioral health interventions delivered during early reentry may reduce fatal overdose risk and demonstrate preliminary acceptability and feasibility. To our knowledge, this is among the first manuscripts to examine overdose outcomes during the critical 2-week post-release period among justice-involved women in North Carolina.

Objectives: National and international guidance recommends verbal screening to identify perinatal patients with substance use problems. However, perinatal patients report negative medical experiences and a rational fear of disclosing substance use due to negative consequences for disclosure. To improve screening experiences and accuracy, this study focused on the input of patients and staff with substance use disorders. Methods: Participants were perinatal patients with substance use histories in a gender-specific treatment program (n=6) or staff (peer support specialists, paraprofessionals, or Qualified Providers) working with perinatal patients (n=14) in a gender-specific substance use disorder treatment program. Qualitative information was gathered in three ways: 1) focus groups with perinatal patients, 2) focus groups with paraprofessionals and QPs, and 3) three individual interviews were conducted. A descriptive phenomenological approach was used for analysis. Results: The three themes that emerged from the perinatal patients with substance use histories group were provider fear of Child Protective Services (CPS), provider competency, and provider compassion. Three themes also emerged from the staff: methods to improve the assessment, concerns related to CPS, and challenges when working with healthcare professionals. Both groups recommended that (1) the screener’s introduction needs to provide information about CPS reporting, (2) patients receive a list of treatment resources, and (3) healthcare providers are trained in compassionate screening. Discussion: Participants recommended that pregnant patients with substance use histories are more likely to share their substance use history if there is a sense of safety through compassionate care. Before screening, healthcare providers should be committed to seeking training to treat perinatal substance use, adopt stigma-free language, support autonomy to disclose substance use history due to previous encounters, and be transparent about the use of the information and outcome, and have treatment resources readily available to reduce the harms of mandatory reporting to CPS.

This chapter focuses on the myriad of factors that are known or suspected to cause neurodevelopmental alterations in children to show the challenge with drawing a clear cause and effect relationship between prenatal opioid exposure and neurodevelopmental outcomes. With this lens, the chapter highlights the current literature and its limitations while providing recommendations and considerations for future studies to make meaningful advances in the care of pregnant and parenting women struggling with opioid use and their prenatally opioid- and other substance-exposed children.

Objectives: For people with opioid use disorder (OUD), transitioning from pregnancy to postpartum and from incarceration to the community is a time of increased risk for opioid overdose. This prospective project evaluated the extent of Jenna’s Project’s success in preventing overdoses and improving recovery outcomes by coordinating postrelease care in incarcerated OUD perinatal patients. Methods: Participants (N = 132) were pregnant or postpartum (1 year postdelivery) with OUD during incarceration and self-referred for postrelease services. From March 2020 to October 2021, participants could receive up to 6 months of postincarceration care coordination services (eg, regular communication, transportation, emergency housing, SUD treatment), medication to treat OUD (MOUD) and other treatment services. Outcomes included verified overdose (fatal), self-reported nonfatal overdose, reincarceration, active Medicaid, receipt of MOUD, presence of children living with participants, open Child Protective Services cases, and number of referrals for services. Results: There were 0 nonfatal and 0 fatal overdoses at both 1 and 6 months postrelease, and 3 of 132 (2%) returned to incarceration. Significantly fewer participants had Medicaid at release (36%) and at 6 months postrelease (60%) than before incarceration (87%) (P < 0.001 for all 3 pairwise comparisons). At 6 months postrelease, significantly more participants reported MOUD receipt (51%) compared with before incarceration (39%) (P < 0.001). There was no significant change in the number of open Child Protective Services cases. Referrals for childcare or parenting services were the most common referrals provided. Conclusion: Immediate postrelease care coordination for pregnant and postpartum women with OUD was feasible and effective in preventing overdose, reincarceration, and promoting recovery outcomes.

Objectives To describe how the UNC Horizons program, a comprehensive women-centered program for pregnant and parenting women with substance use disorders, and its patient population have changed over time and summarize basic neonatal outcomes for infants born to women in treatment at Horizons. Methods Yearly Annual Reports from fiscal years of 1994 to 2017 were abstracted. Patient characteristics and infant outcomes compared to normative North Carolina data were examined. Results Highlights of findings include: The percentage of women for whom opioids were the primary substance of use increased from 0% in 1995–1996 to 62% in 2016–17, while cocaine decreased from 66 to 12%. Intravenous substance use history increased from 7% in 1994–1995 to 41% in 2016–2017. The number of women reporting a history of incarceration rose from 10–20% in the early years to 40%-50% beginning in 2007–2008. The proportion of women reporting a desire to hurt themselves rose from 20% in 2004–2005 to 40% in 2016–2017. Self-reported suicide attempt history remained consistent at 32% across years. While reporting of childhood physical abuse remained at 38% across years, reporting of sexual abuse and domestic violence trended upward. Horizons did not differ from North Carolina in the likelihood of patients giving birth prematurely [χ²(13) = 20.6,p = .082], or the likelihood of a patient giving birth to a low birthweight infant [χ²(13) = 14.7,p = .333]. Conclusions for Practice Breaking the cycle of addiction for women and children must focus on helping women with substance use problems develop a sense of hope that their lives can improve, and a sense of feeling safe and nurtured.

The United States remains in the midst of at least its third opioid overdose epidemic. Within this current overdose epidemic are several distinct waves beginning with prescription opioid deaths in ...