A Tiered Framework for Outpatient Perinatal Substance Use Disorder Services

Substance use disorder (SUD) during pregnancy and the postpartum period presents unique clinical and structural challenges that require integrated, evidence-based care. The intensity of perinatal care visits creates a critical opportunity to embed treatment for SUD within routine medical services. While many models of perinatal SUD (PSUD) care exist, they vary widely in structure and scope. A foundational and adaptable framework is needed to support implementation, promote consistency, and evaluate care quality across diverse health care settings. This manuscript presents a tiered framework for outpatient PSUD care, adapted from the SAMHSA-HRSA Integrated Behavioral Health model. The framework outlines 3 core domains: (1) Team Scope of Services, (2) Systematic Communication, and (3) Degree of Coordination stratified across 3 tiers that reflect increasing levels of integration and service maturity. By defining the components of integrated PSUD care, this model provides a shared language for clinical teams, researchers, and policymakers. The framework is illustrated through examples from established PSUD programs in Virginia and North Carolina, highlighting real-world application. Common challenges and regional considerations, including the unique needs of Appalachian populations and financial sustainability, are also discussed. This framework serves as a beginning tool for quality improvement, research, and health system planning. It prioritizes patient-centered care and scalability, supporting risk-appropriate models of PSUD treatment. By promoting consistency in service delivery, this approach aimed to improve mother-baby dyad outcomes and reduce overdose-related mortality.