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Best practice №10

Initiate medication assisted treatment in the prenatal setting

by Holly Smith, Tipu V. Khan

Last updated September 3rd, 2020

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Implement an outpatient protocol for evidence-based evaluation, treatment, and continuity of care for pregnant patients with opioid use disorder (OUD). Arranging for the provision of medication assisted treatment (MAT) on site is an optimal way to deliver the standard of care for pregnant women with OUD. 

Why we are recommending this best practice

The pregnant woman with OUD who presents for prenatal care has a unique opportunity to initiate treatment for OUD. While the care team may initially find such a patient challenging, they have a chance to introduce life-changing therapy. Along with the screening and brief intervention portions of SBIRT, obstetric providers can offer MAT treatment. Few obstetric providers have received training in OUD management and understandably feel reluctant to begin this practice. Obstetric providers often feel more comfortable referring patients with OUD to a stand-alone outpatient opioid treatment clinic or other office-based outpatient treatment (OBOT) program for induction and management of OUD with MAT. However, the desired future state in opioid treatment is for patients with OUD to be able to begin treatment wherever they receive medical or prenatal care. Providers who can initiate treatment for OUD will have a significant impact on the unmet treatment gap in their county. 

Strategies for implementation

  • Engage the whole team. Successful integration of a new service will require front office, back office, and providers all educated about the successful outcomes in pregnant women with OUD who are on MAT. 

  • Providers must receive a Drug Addiction Treatment Act of 2000 (DATA 2000) X waiver to be able to prescribe MAT. Federal legislation (SUPPORT Act, 2018) and previous legislation includes CNMs, NPs, and CRNAs in addition to physicians as eligible to complete this training. Online training programs are readily available. Physicians require 8 hours of training, and non-physician providers require 24 hours of training. 
  • Build policies/procedures for MAT to allow for a uniform care delivery system.

  • Use a toolkit. Numerous toolkits exist that provide clinics with the education and resources needed to offer MAT. One such is example is the Providers Clinical Support System (PCSS).

  • Identify who to call for help. Know how to refer patients who fail buprenorphine to methadone treatment programs when necessary. Consider using a consultation service such as the FREE Clinician Consultation Center at UCSF which has a Substance Use Warmline at 855-300-9595 and is available Monday through Friday during daytime business hours, and a specific Consultation line for licensed practitioners in California that is available 24/7. This line is staffed by physicians, pharmacists, and nurses with special expertise in pharmacotherapy options.

  • Explore emerging therapies. Aside from traditional in-office induction, consider other modalities that best suit your patients. These include home and hospital induction, micro-dosing transition, and Buprenorphine Quick Start. 



  • Laws and Regulations. Substance Abuse and Mental Health Services Administration. Updated April 27, 2020.
  • Apply for a Practitioner Waiver. Substance Abuse and Mental Health Services Administration. Updated April 16, 2020.

Holly Smith


Holly Smith is a certified nurse-midwife with 20 years' experience in diverse practice settings. She is the project manager for the CMQCC/CPQCC Mother and Baby Substance Exposure Initiative. Previous to this role, she was a the lead editor for the CMQCC Toolkit to Support Vaginal Birth and Reduce Primary Cesareans, and a clinical lead for the CMQCC Collaborative to Support Vaginal Birth and Reduce Primary Cesareans, a large-scale quality improvement project with over 90 California hospitals. Her primary role as clinical lead focused on assisting southern California hospitals with the implementation of evidence-based practices to reduce cesarean. She is a hospital coach and steering committee member for the American College of Nurse-Midwives' Reducing Primary Cesareans Project, and expert consultant on various national and state quality improvement and health policy initiatives. Additionally, she chairs the Health Policy Committee of the California affiliate of the American College of Nurse-Midwives and is a health policy consultant to the California Nurse-Midwives Foundation. 

Tipu V. Khan


Dr. Khan is an Addiction Medicine specialist and Chief of Addiction Medicine consult-liaison service and outpatient specialty clinic at Ventura County Medical Center. He is the medical director of Prototypes Southern California which has hundreds of residential treatment beds as well as medical-withdrawal (detox) beds throughout Southern California. Dr. Khan is the Medical Director of the Ventura County Backpack medicine group, and Primary Care Hepatitis C Eradication Project. His niche is managing SUD in pregnancy and is a national speaker on this topic.