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Rural Health Information Hub

Models Addressing Substance Use Disorders (SUD)

Rural communities are implementing evidence-based and promising models to treat substance use disorders. Please see the Rural Prevention and Treatment of Substance Use Disorders Toolkit for examples.

There are many clinical and community-based interventions that address substance use disorders (SUD), including tobacco use and opioid use disorder (OUD) in pregnant women.

The U.S. Preventive Services Task Force recommends that clinicians screen all pregnant women for tobacco use, advise them to stop using tobacco, and offer behavioral interventions for tobacco cessation. The recommendations suggest using the 5 A's framework to assess smoking status (ask, advise, assess, assist, and arrange), then refer to behavioral interventions such as counseling, health education, incentives, and social support.

The evidence-based approach most frequently recommended and used for pregnant women with OUD is called medications for opioid use disorder (MOUD). MOUD is the use of medications approved by the U.S. Food and Drug Administrations (FDA) for the treatment of OUD.

The Substance Abuse and Mental Health Services Administration and the American Society of Addiction Medicine have each published guidelines for the treatment of pregnant women with OUD. The American College of Obstetricians and Gynecologists has recommendations on screening, intervention, and referral to treatment procedures for providers.

Examples of Models Addressing SUD

  • The National Congress of American Indians (NCAI) is a nonprofit organization serving tribal governments and communities. NCAI collaborates with Native communities across the country to address the opioid epidemic in Indian Country. Several tribes have built integrated behavioral health networks to support American Indian women with SUD. An example would be the 4P's Plus Pregnancy Support Project. Programs such as 4P's have successfully reduced exposure of American Indian babies to alcohol, tobacco, and other drugs.
  • Funded by the Centers for Medicare and Medicaid Services, the Maternal Opioid Misuse (MOM) Model addresses inconsistent care received by pregnant and postpartum Medicaid beneficiaries with OUD. The MOM Model has a 5-year performance period from Fall 2019 to Fall 2024 offering different types of funding and focuses on integrating clinical care with other services and resources that are critical for recovery in this population.
  • Projects such as the New England community-based program, Engaging Mothers for Positive Outcomes with Early Referrals (EMPOWER), are aimed at providing early support to rural women with perinatal SUD. Women receive comprehensive screening, referral, and individualized pregnancy plans through coordinated care from the first prenatal visit through discharge after giving birth. This interdisciplinary program has shown feasibility and effectiveness in addressing the needs of these vulnerable populations and the communities that serve them.
  • Some Tennessee communities developed interdisciplinary programs in which licensed social workers and case managers conduct home visits, support groups, and individual therapy sessions to assess patients' behavioral health. Since 2006, the Mothers and Infants Sober Together (MIST) program has aligned resources that support the needs of pregnant women who are using substances and infants born into drug-positive families.
  • A promising model uses web-based smoking cessation programs to offer monetary incentives to pregnant women and adolescents in Appalachian regions of eastern Kentucky and Ohio to reduce smoking. Participants have significantly reduced their smoking rates or have quit altogether.
  • The South Dakota QuitLine offers phone-based smoking cessation to pregnant women and a postpartum program to prevent relapse after delivery that has had success in the area. While more monitoring and evaluation is needed, this intervention has initially shown participants significantly reducing their smoking rates or quitting altogether.
  • The BABY & ME – Tobacco Free Program is an evidence-based program that helps families quit smoking during the prenatal period, and then incentivizes them to remain quit after birth. There are no age or income requirements, and in many locations, a qualifying partner may be eligible to enroll with the pregnant partner. In Tennessee, the program demonstrated an 11% reduction in low birthweights by participants and reduced hospital charges of newborn care estimated at $1.9 million.

For more information about programs to address SUD and tobacco, visit the Rural Prevention and Treatment of Substance Use Disorder Toolkit and the Rural Tobacco Control and Prevention Toolkit.

Program Clearinghouse Examples

Considerations for Implementation

Estimated annual costs of neonatal healthcare related to smoking while pregnant are almost $367 million. However, estimates indicate that for every dollar spent on cessation programs for pregnant women, $3 are saved in neonatal intensive care costs. There are several free resources available to pregnant women, including Smokefree Women and the Center for Disease Control and Prevention's Tips from Former Smokers promoting quitlines.

There is a need for guidelines specifically addressing pregnant women with OUD in rural communities. Adequate and timely access to prenatal services for women with OUD have shown to improve birth outcomes and lower perinatal complications. However, geographic disparities are a major barrier affecting obstetric treatment. Current state laws criminalize substance use during pregnancy, which makes it difficult for mothers to seek help from providers out of fear of legal consequences. Rural facilities should be adequately equipped to care for pregnant women with OUD and their babies. Medication-Assisted Treatment (MAT) with an emphasis on pregnancy is one possible intervention. The U.S. Department of Health and Human Services is committed to improving access to MAT via telehealth, which could increase the availability of this service in rural communities. Additionally, the U.S. Food and Drug Administration has recently cleared an OUD prevention app to support expecting mothers with OUD.

Resources to Learn More

Behavioral Health Treatment Services Locator
Mapping System
An interactive map that allows users to identify local treatment facilities addressing substance use disorder and mental health concerns across the U.S.
Substance Abuse and Mental Health Services Administration (SAMHSA)

Smoking & Tobacco Use – State and Community Resources
Collection of evidence-based guides on tobacco control programs with a focus on cessation, communication interventions, health equity, and youth engagement. Provides data and statistics by state on tobacco use, tracking and evaluation of tobacco control programs, and smoking mortality, morbidity, and economic costs.
Organization(s): Centers for Disease Control and Prevention

Substance Use Resources for All Providers
Repository of online resources, information sheets, professional recommendations, and toolkits for providers who are treating pregnant women with OUD.
Organization(s): Massachusetts Child Psychiatry Access Program (MCPAP)