A Family Approach to Services and Transitions for Opioid Use & Exposure

Mental health conditions, including drug-related overdose deaths and suicides, are the top cause of pregnancy-related deaths in Pennsylvania, contributing to 34% of deaths in 2021. The highest risk occurs in the postpartum period. The Maternal Mortality Review Committee (MMRC) also identified substance use disorder (SUD) contributed to 26% of the deaths, and 98% of all deaths were preventable.1

To prevent these deaths, the MMRC recommends that providers screen for SUD and co-occurring disorders, make warm handoff referrals, standardize discharge plans for postpartum individuals with opioid use disorder (OUD) including naloxone prescription and distribution, consult multi-disciplinary care teams specific to SUD at time of admission, provide medications for OUD or ensure adequate treatment from SUD facilities, follow-up with individuals with SUD after discharge, ensure services and appointments are in place with a closed loop referral prior to discharge, ensure equity use and application of a Plans of Safe Care, ensure standard protocols in place to avoid stigma and discrimination for individuals who are suspected of using substances. 

For Neonatal Abstinence Syndrome (NAS), the incidence per 1,000 live births in 2023 was 9.1—a decrease from the 2022 rate of 9.6. In regard to the discharge plan and referrals for those with NAS, 62% had a Plan of Safe Care initiated, 31% were referred to Early Intervention, 11% were referred to home visiting services, and 51% were referred to pediatricians experienced with NAS, among other referrals. PA DOH’s NAS report describes the opportunity to improve awareness and education of hospital providers on available services and the importance of coordinated follow-up and referral.2

 

Sources

1 PA Maternal Mortality Review 2021 Case Data Infographic. PA Department of Health. https://www.pa.gov/content/dam/copapwp-pagov/en/health/documents/topics/documents/programs/2025%20Pennsylvania%20Maternal%20Mortality%20Review%20Infographic%E2%80%8B.pdf. October 16, 2025.

*2025 PA Maternal Mortality Review Annual Report, Deaths occurring in 2021 (Full Report).  https://www.pa.gov/content/dam/copapwp-pagov/en/health/documents/topics/documents/programs/2025%20MMR%20Report.pdf. August 2025.

2 Neonatal Abstinence Syndrome: 2023 Report Bureau of Family Health and Bureau of Epidemiology April 2025. https://www.pa.gov/content/dam/copapwp-pagov/en/health/documents/topics/documents/opioids/NAS%202023%20Annual%20Report.pdf

Successes

Provide Naloxone Prior to Discharge
Increased from 22 to 30 hospitals with a system in place to provide naloxone to at-risk patients prior to discharge.
%
Screened With a Validated Tool
Sustained over 90% of pregnant individuals being screened for substance use with a validated tool.
%
Non-Pharmacological Care
Sustained 90% of substance-exposed newborns receiving non-pharmacological care.
Trauma-Informed Care Trainings
Trained 20 hospitals in trauma-informed care.
Perinatal TiPS
In 2024, PA established the Perinatal TiPS Program to offer provider-to-provider consultation, referral assistance, and case management support for perinatal mental health and SUD across all 67 counties in the Commonwealth.

2026-2027 Goals

Recruit 20 multidisciplinary healthcare teams to participate in PA PQC’s OUD and NAS initiative.

Standardize the discharge and transition process for people with OUD among at least 50% of participating hospitals.

Standardize the discharge and transition process for babies with NAS among at least 50% of participating hospitals.

Train 5 hospitals in trauma-informed care approaches and establish a trauma-informed approach within all 5 hospitals in the context of substance use.

Key Interventions

Standardize provision of opioid reversal medication and education on overdose prevention and harm reduction strategies during the discharge and transition process.

Standardize education for families on care needs and harm reduction strategies.

Standardize coordination of care transitions, including warm handoffs and connection to postpartum and newborn services.

Standardize use of evidence-based guidance, such as medications for OUD, treatment of NAS, and breastmilk feeding recommendations.

Provide access to lactation consultation.

Follow-up after discharge to support ongoing connection to care.

Train hospital leadership and staff on how to provide non-stigmatizing, trauma informed OUD and NAS care to meet the individualized needs of diverse populations, including Black maternal health concerns.

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Folder Family Approach to OUD/NAS

Documents

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pdf A Family Approach to OUD and NAS Initiative Brief ( pdf, 130 KB ) (5 downloads) New