Description

Pregnant and postpartum individuals with opioid use disorder (OUD) experience a disproportionate burden of morbidity, mortality, and overdose risk in the United States. Increasingly, this population is affected by co-occurring stimulant use disorder (StUD), which further complicates treatment engagement and outcomes. Although many individuals attempt to discontinue substance use during pregnancy, withdrawal symptoms, psychosocial stressors, stigma, and unmet health-related social needs frequently contribute to return to use. Return to use is strongly associated with treatment disengagement, adverse maternal and neonatal outcomes, and increased risk of overdose.

Medication for opioid use disorder (MOUD), including buprenorphine and methadone, is the standard of care during pregnancy and is associated with reduced overdose risk and improved outcomes. However, MOUD alone is often insufficient to address complex behavioral, social, and structural barriers to sustained recovery. In addition, there are no FDA-approved medications for stimulant use disorder, and optimal behavioral strategies to address co-occurring OUD and StUD and improve treatment retention remain unclear.

Existing integrated and comprehensive care models have shown benefits but are often resource-intensive, difficult to scale, and may inadequately address social determinants of health and patient self-management. Patient Navigation (PN) is a patient-centered, scalable model designed to reduce barriers to care, improve coordination across fragmented health and social service systems, and provide individualized motivational support. PN has demonstrated effectiveness across chronic health conditions and shows promise for improving outcomes among pregnant persons with OUD.

This study evaluates an enhanced PN intervention for pregnant persons with OUD with or without co-occurring StUD (OUD±StUD). The intervention integrates strengths-based case management, motivational interviewing, and contingency management (CM), an evidence-based behavioral approach that reinforces treatment engagement and behavior change through incentives and is among the most effective interventions for stimulant use.

This mixed-methods, type 2 hybrid effectiveness-implementation study includes three components:

Intervention Development (Specific Aim 1):

The PN model will be refined to incorporate CM strategies targeting stimulant use. Development will follow an evidence-informed adaptation framework and involve multidisciplinary experts and individuals with lived experience. The result will be an enhanced PN intervention manual and navigator training approach designed to address both OUD and StUD within the perinatal context.

Implementation Strategy Development (Specific Aim 2):

Qualitative interviews and focus groups will be conducted with Medicaid program leaders, healthcare professionals, and individuals with lived experience to identify barriers and facilitators to implementing PN within Medicaid systems. Using implementation science frameworks, findings will be translated into a structured implementation playbook outlining strategies for adoption, integration, and sustainability of PN services in real-world settings.

Randomized Controlled Trial (Specific Aim 3):

The effectiveness of PN will be evaluated in a randomized controlled trial comparing PN to usual care (UC), defined as standard case management and referral services. Eligible participants will include pregnant individuals (≥18 years) with diagnosed OUD, newly initiated on MOUD, and enrolled in participating Medicaid managed care plans.

Participants will be randomized 1:1 to PN or UC. The PN intervention will include up to 10 prenatal sessions and 4 postpartum sessions delivered by trained navigators via phone, telehealth, or in-person. Sessions will focus on facilitating linkage to and retention in substance use treatment, MOUD adherence, engagement in medical and behavioral health care, and connection to social services addressing health-related social needs. The intervention also incorporates contingency management to reinforce treatment participation and behavior change. Usual care participants will receive standard health plan care management services and referrals.

The primary outcome is change in illicit opioid use, measured using urine toxicology screening and the Timeline Follow-Back method. Secondary outcomes include stimulant use, MOUD adherence, participation in substance use treatment, non-fatal overdose, and resolution of health-related social needs. Additional outcomes include healthcare utilization and costs for both participants and their infants, derived from administrative claims and medical records.

Implementation outcomes will be assessed using the RE-AIM framework, including reach (enrollment and participation), effectiveness (clinical outcomes), adoption (organizational readiness), implementation (intervention fidelity), and maintenance (sustained healthcare utilization and outcomes).

This study is conducted within Medicaid managed care settings, which provide a highly relevant and scalable context given that Medicaid covers a substantial proportion of U.S. births and individuals with OUD. By integrating intervention development, implementation planning, and a rigorously designed randomized trial, this study aims to generate actionable evidence regarding both clinical effectiveness and real-world feasibility.

Findings from this study are expected to inform broader dissemination of patient navigation within Medicaid and other healthcare systems, with the goal of improving treatment engagement, reducing substance use and overdose risk, and improving maternal and neonatal outcomes.