State Strategies to Address Opioid Use Disorder Among Pregnant and Postpartum Women and Infants Prenatally Exposed to Substances, Including Infants With Neonatal Abstinence Syndrome

Charlan D. Kroelinger, PhD; Marion E. Rice, MPH; Shanna Cox, MSPH; Hadley R. Hickner, MS; Mary Kate Weber, MPH; Lisa Romero, DrPH; Jean Y. Ko, PhD; Donna Addison, MPH; Trish Mueller, MPH; Carrie Shapiro-Mendoza, PhD; S. Nicole Fehrenbach, MPP; Margaret A. Honein, PhD; Wanda D. Barfield, MD


Morbidity and Mortality Weekly Report. 2019;68(36):777-783. 

In This Article

Abstract and Introduction


Since 1999, the rate of opioid use disorder (OUD) has more than quadrupled, from 1.5 per 1,000 delivery hospitalizations to 6.5,[1] with similar increases in incidence of neonatal abstinence syndrome (NAS) observed for infants (from 2.8 per 1,000 live births to 14.4) among Medicaid-insured deliveries.[2] CDC's response to the opioid crisis involves strategies to prevent opioid overdoses and related harms by building state capacity and supporting providers, health systems, and payers.* Recognizing systems gaps in provision of perinatal care and services, CDC partnered with the Association of State and Territorial Health Officials (ASTHO) to launch the Opioid Use Disorder, Maternal Outcomes, and Neonatal Abstinence Syndrome Initiative Learning Community (OMNI LC). OMNI LC supports systems change and capacity building in 12 states. Qualitative data from participating states were analyzed to identify strategies, barriers, and facilitators for capacity building in state-defined focus areas. Most states focused on strategies to expand access to and coordination of quality services (10 of 12) or increase provider awareness and training (nine of 12). Fewer states focused on data, monitoring, and evaluation (four of 12); financing and coverage (three of 12); or ethical, legal, and social considerations (two of 12). By building capacity to strengthen health systems, state-identified strategies across all focus areas might improve the health trajectory of mothers, infants, and families affected by the U.S. opioid crisis.

Guidance for pregnant and postpartum women with OUD includes universal screening for substance use during pregnancy; provision of medication-assisted treatment and behavioral counseling during pregnancy and the postpartum period; anticipation and management of NAS for infants prenatally exposed to substances; and multidisciplinary, long-term follow-up care for mothers and infants to improve outcomes.§ Provision of services requires coordinated effort among providers, health departments, and other state and local agencies, including residential treatment programs, housing authorities, and child welfare agencies. OMNI LC uses a learning collaborative framework[3] that is designed to support states in developing and implementing systems change on complex public health issues.

As part of the learning collaborative framework, 12 state teams, comprising leaders from multidisciplinary agencies,** participated in a 2-day meeting in Arlington, Virginia, in November 2018, with support from ASTHO, CDC, and other federal and academic partners.†† Five focus areas were defined: 1) access to and coordination of quality services; 2) provider awareness and training; 3) data, monitoring, and evaluation; 4) financing and coverage; and 5) ethical, legal, and social considerations. State teams developed plans of action within one or more focus areas and outlined activities to accomplish goals. CDC abstracted data from state action plans and other information sources (i.e., topic-specific discussion notes and state presentations). CDC coded data and identified strategies, existing barriers, and facilitators.§§ Codes were validated by a separate group of CDC researchers using the same codebook; differences were resolved through consensus.

* CDC opioid portal site.
Twelve states were identified for participation in the first year of OMNI LC: Alaska, Florida, Illinois, Kentucky, Nevada, Ohio, Pennsylvania, Rhode Island, Tennessee, Vermont, Washington, and West Virginia. States were invited to participate in OMNI LC based on a high prevalence or incidence of opioid-related behaviors and outcomes (e.g., NAS incidence, OUD prevalence, overdose death rates), available treatment for OUD (e.g., medication-assisted treatment for pregnant and postpartum women), a declared state of emergency, and state-initiated or -developed interventions to address the opioid crisis.
** The following leaders participated on state teams: state health official; Medicaid medical director; behavioral, mental health, or alcohol and drug abuse director; Title V director; and a provider or facility champion. Each state team was composed of a minimum of five members representing the leadership described above. States might have included additional state staff members to support leadership participating in the meeting.
†† Participants of the in-person meeting included representatives of the following organizations: American College of Obstetricians and Gynecologists, Association of Maternal and Child Health Programs, Centers for Medicare & Medicaid Services, Health Resources and Services Administration, National Association of State Alcohol and Drug Abuse Directors, Substance Abuse and Mental Health Services Administration, Administration for Children and Families, and University of Illinois at Chicago.
§§ A strategy is defined as a method or technique used to enhance the adoption, implementation, and sustainability of a program, practice, or policy. Strategies should identify/define discrete components operationally, including: who enacts the strategy (actor); actions, steps, or processes, using active verb statements (action); and the target of the strategy (action target). . Barriers and facilitators are defined as factors obstructing or enabling improvements, presenting problems or providing incentives, by moderating or mediating public health practice, programs, or policies.