Improve Access to Recovery Coaches for Mothers

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Introductory Paragraph

New motherhood is an incredibly stressful period of life for women, as they adjust to the physical and mental demands of caring for a newborn, make peace with their new lifestyle, heal from the birth, and a myriad of outside factors that influence this new phase. These new life hurdles are exacerbated for new mothers with a substance use disorder who are trying to get to or maintain sobriety on top of having a new baby. Relapse rates for new mothers are incredibly high at 80% during the first year after their baby is born, made worse by the risks and cyclical effects of postpartum depression both unrelated and related to substance use[1], [2]. Becoming sober and maintaining sobriety is no easy feat by itself, just as new motherhood is not; the combination of both circumstances is one that clinicians need to address with the utmost care, respect, and diligence. These fragile states of being may be best addressed through the addition of a recovery coach in the new mother's support team.


Key Information

Sobriety during pregnancy is a lofty and important goal, but about 853% of pregnant women with a SUD are able to maintain abstinence from at least one substance while they are carrying the baby[3]. However, the first year of postpartum is very dangerous for women who struggle with SUD, as noted above with the high relapse rate. Mothers who have a SUD face challenges that may propel them towards relapses, such as food insecurities, legal troubles, the threat of infant removal, and domestic turmoil. Resources to aid the new mother in her recovery need to extend beyond birth and be tailored to the unique situations these mothers face with their addiction.

What is a Recovery Coach?

The definition of a recovery coach and their responsibilities will vary from program to program, so discussed will be a general depiction of what a recovery coach is. A study exploring the efficacy of nine recovery coaching programs done by OPRE described recovery coaches (RC) who work in the child welfare system as those who work with parents who have had a child or are at risk of having a child removed from their care due to SUD [4]. They, “increase access to and engagement in treatment and other services to support parents’ recovery, coordinate with child welfare agency staff, and ensure treatment and recovery progress is incorporated into plans to either maintain children with their families of origin or place them with other permanent families,” [5]. Some programs may require a bachelor’s degree but many others employ peer recovery coaches who have lived experience, whether they have had success in SUD recovery and new parenting or have been directly involved with a loved one in that situation (6, 7)[6],[7].

White, in conjunction with the PRO-ACT Ethics Workgroup, published an ethical guideline for peer-based recovery when the recovery coach is not a licensed clinician [8]. According to these guidelines, employed peer recovery coaches are meant to provide emotional, informational, and instrumental support along with companionship in recovery [9]. White notes the need for these ethical guidelines, as the description of many programs presents overlapping duties with other treatment players; these guidelines provide a clear-cut picture of the competencies and responsibilities of a recovery coach to prevent any role confusion and potential unqualified treatment [10]. A recovery coach following these guidelines is a(n):

  • Outreach worker
  • Motivator and cheerleader
    • Offers a living example of hard work/recovery success
    • Encourages & celebrates recovery milestones
    • Encourages & models self-advocacy and self-sufficiency
  • Ally & confidant - can be trusted, cares, and listens
  • Truthteller - provides honest, constructive feedback on recovery progress
  • Role model & mentor
  • Planner
  • Problem solver
  • Resource broker
  • Monitor
  • Tour guide
  • Advocate
  • Educator
  • Community organizer
  • Lifestyle consultant/guide
  • Friend

It is key to note that a recovery coach is NOT a:

  • Sponsor
  • Therapist/counselor
  • Nurse/physician
  • Priest/clergy

Tasks that fall into the wheelhouse of these professions should not be permitted and always referred out [11]. A third definition, put forth by the NC Pregnancy and Opioid Exposure Project, establishes the recovery coach as a “paraprofessional who assists parents in obtaining needed benefits, coordinates child welfare and substance abuse treatment staff, and connects the family with treatment providers,” [12]. While they are independent of these agencies, they will often be at home visits with agents from child welfare and substance abuse treatment programs [13].

Importance of Recovery Coaches in the Postpartum Period

Mothers with a SUD are a priority for substance treatment while pregnant, as the continued use can have a major impact on the fetus. However, many women, regardless of insurance status, see their treatment options dwindle postpartum, as the shift of medical attention goes from the mother to the infant [14]. Programs that implement a recovery coach have seen success with achieving and maintaining postpartum sobriety because the coach has unique, lived experience that they provide to help navigate these struggles. An evidence-based review of one program out of Illinois found that parents with their baby removed from care who had access to a postpartum recovery coach had a 15% increase in parent-child reunification, a 14% increase in having foster-care cases closed, and, importantly, there was no evidence of adverse impact in the increased/quicker reunification and case-closure rates[15]. With so much stigma surrounding new mothers with a SUD, the goal of recovery coaching is to empower the mother without judgment [16]. The coach’s lived experience can bring a sense of hope and trust to the new mother, upon seeing a peer who has gone through similar circumstances have success in maintaining sobriety. Because the recovery coach has had life experience coupled with paraprofessional training, they provide a unique and knowledgeable insight into the ins and outs of recovery and all the agencies and resources involved with recovery and child welfare. White’s paper on the ethics of recovery coaching provides testimonials from mothers on how impactful their coach was in their recovery, many of whom echo the importance of building a strong relationship, outside the stressors of therapies and agencies, built on mutual understanding and unwavering support [17]. The effectiveness of the lived experience and later training of the recovery coach cannot be understated in its value to comprehensive SUD treatment for new mothers[18].

The integral role of recovery coaches in building esteem, support, and providing inter-agency resources helps to bolster the effects of treatment for new mothers, as well as giving them the tools to work towards sobriety. SUDs are one of the main contributors to child removal and failed reunification of the child and parent; the help of recovery coaches in reaching and maintaining sobriety has been shown to greatly impact the outcomes of parental-child cohabitation[19],[20].

Consideration: Comorbidity of SUD and PPD

Substance use disorder and postpartum depression are commonly identified as comorbidity, regardless of which condition came first [21]. It is important that the recovery coach not blur the lines in giving clinical advice regarding postpartum depression and maintain services within their own wheelhouse. However, the co-occurrence of the two conditions may indicate a greater need for the recovery coach, as they can alleviate some of the burdens of finding resources while providing social support that is critical for those with depression [22],[23].

Relevant Research

As discussed above, this evidence-based review of a recovery coach program in Illinois showed promising improvements for the reunification of children put in foster care due to parental SUD. Not only were the children reunified at a greater capacity and faster, but their foster care cases were also closed sooner than expected and had greater outcomes for parental-child retention.[24]

The OPRE Report 2021 reviews 9 recovery coaching interventions for a comprehensive look at the replicability, success, and readiness of the programs. It discusses the strengths, weaknesses, and evidence-based practice implications of each practice model.[25]

Eddie, et al. (2019) provide a systematic review of to-date peer recovery support services and recovery coaching. The comprehensive review of programs reassures the known potential of recovery coaching in SUD treatment and also highlights the fact that more extensive research needs to be done in order to empirically support its inclusion, as well as the need to provide a clear role definition. It’s important to note that this review is not specific to postpartum recovery coaching, but its umbrella impact on aiding SUD treatment.[26]

A study conducted by Talyor, Stewart, and Howard (2018) highlights the high risk of relapse (28.3%) in the first three months postpartum, especially amongst those with comorbid mental illness.[27]

Gaps

There isn’t a lot of statistical research done on the effectiveness of recovery coaches postpartum; the above research is what is readily available for quantitative data. A reason for this may be that many mothers have access to these programs while pregnant, but lose it postpartum due to insurance restrictions or loss. There are 17 states that don’t provide Medicaid for young adults; though they recieve it while pregnant, coverage stops 60 days after birth (4). Those who do retain their coverage face challenges in navigating postpartum coverage changes, finding new doctors to give them SUD treatment referrals, and new and confusing paperwork. Looking at the slightly larger research database on the effectiveness of recovery coaches during pregnancy can be a springboard for advocacy in postpartum treatment.

Impactful Federal, State, and Local Policies

Please see below for state-by-state Medicaid postpartum coverage affecting access to resources.

Virginia provides a scholarship to help cover fees in becoming a Certified Peer Recovery Specialist[28]

Recovery support services, including recovery coaches, were included in the Comprehensive Addiction Recovery Act but not funded. Implementation varies state by state, as does access requirements.[29]

There is no federal definition of recovery services. 37 states provide coverage for some type of peer SUD support but they all have various guidelines and restrictions.

  • 17 states discontinue Medicaid coverage 60 days postpartum[30]

Available Tools and Resources

Safe Project Addiction and Mental Health Resources for Women[31]

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an early intervention and treatment approach for SUD. It can be used to direct the clinician to appropriate resources depending on the patient.[32]

BRSS-TACS provides a state-by-state directory of training and certification programs for peery recovery coaching.[33]

The National Center on Substance Abuse and Child Welfare has published their guide, “The Use of Peers and Recovery Specialists in Child Welfare Settings,” which covers models, implementation, funding, qualifications/training, supervision, and much more. It is a good tool for practices wishing to implement recovery coaches and peer support.[34]

KFF has provided a breakdown of postpartum Medicaid coverage state-by-state, addressing gaps, disparities, and needs. This coverage greatly impacts new mothers with a SUD, who are more likely to need continuity of Medicaid coverage to aid in their recovery.[35]

The Montgomery County Office of Mental Health has published its recovery coaching guidelines. It is a comprehensive guide on how to effectively implement recovery coaching in the community to address a wide array of vulnerable populations.[36]

Promising Practices

Certified Addiction Recovery Empowerment Specialist (CARES) - developed by the Georgia Council on Substance Abuse, CARES works to provide peer recovery support services. They provide training, examination, and continuing education to maintain their strengths-based approach. They provide:

  • A Recovery coaches for SUD
  • A CARES Warm Line (a call line to aid those struggling, needing to talk to someone, and wanting to remain anonymous) that builds on client’s strengths
  • An emergency department, providing recovery coaches to those experiencing an overdose or other substance-related insident and in need of immediate aid
  • NICO peer recovery support[37]

Sobriety Treatment and Recovery Teams (START) - an “intensive child welfare program for families with substance use and child abuse or neglect built on cross-system collaboration and integrated service delivery.” START utilizes peer recovery coaches in long-term recovery in conjunction with families, treatment providers, and court systems to provide a “system-of-care and shared decision-making approach.” This program is both child welfare and SUD treatment centered and uses trauma-informed care to help maintain safety, reduce child-removal-of-care, achieve and maintain parental sobriety, improve parenting skills, and improve inter-agency collaboration. The site includes program goals, their logic model, components, delivery, training/manuals, implementation, published & reviewed research, and more references [38]

Relevant Resources for Recovery Coach Efficacy (not postpartum)[39]

  • American Society of Addiction Medicine (ASAM)[41]

Sources

  1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4387084/
  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3742364/
  3. https://www.recoveryanswers.org/research-post/stopping-starting-substance-use-pregnancy/
  4. https://www.acf.hhs.gov/sites/default/files/documents/opre/R3-recovery-coaching-march-2021.pdf
  5. https://www.acf.hhs.gov/sites/default/files/documents/opre/R3-recovery-coaching-march-2021.pdf
  6. https://www.naadac.org/assets/2416/whitew2007_the_pro-act_ethics_workgroup.pdf
  7. https://www.medstarhealth.org/-/media/project/mho/medstar/pdf/msh-ch-peer-recovery-coach-brochure_final.pdf
  8. https://www.naadac.org/assets/2416/whitew2007_the_pro-act_ethics_workgroup.pdf
  9. https://www.naadac.org/assets/2416/whitew2007_the_pro-act_ethics_workgroup.pdf
  10. https://www.naadac.org/assets/2416/whitew2007_the_pro-act_ethics_workgroup.pdf
  11. https://www.naadac.org/assets/2416/whitew2007_the_pro-act_ethics_workgroup.pdf
  12. https://ncpoep.org/guidance-document/treatment-matters/approaches-to-treatment/
  13. https://ncpoep.org/guidance-document/treatment-matters/approaches-to-treatment/
  14. https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2018/08/14/for-addicted-women-the-year-after-childbirth-is-the-deadliest
  15. https://evidencebasedprograms.org/programs/recovery-coaches/
  16. https://www.acf.hhs.gov/sites/default/files/documents/opre/R3-recovery-coaching-march-2021.pdf
  17. https://www.acf.hhs.gov/sites/default/files/documents/opre/R3-recovery-coaching-march-2021.pdf
  18. https://www.naadac.org/assets/2416/whitew2007_the_pro-act_ethics_workgroup.pdf
  19. https://ncpoep.org/guidance-document/treatment-matters/approaches-to-treatment/
  20. https://evidencebasedprograms.org/programs/recovery-coaches/
  21. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3742364/
  22. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3742364/
  23. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3518627/
  24. https://evidencebasedprograms.org/programs/recovery-coaches/
  25. https://www.acf.hhs.gov/sites/default/files/documents/opre/R3-recovery-coaching-march-2021.pdf
  26. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6585590/
  27. https://www.sciencedirect.com/science/article/pii/S0920996418304833
  28. https://virginiapeerspecialistnetwork.org/getting-started/
  29. https://www.safeproject.us/safe-takes/treatment-recovery/
  30. https://www.macpac.gov/wp-content/uploads/2019/07/Recovery-Support-Services-for-Medicaid-Beneficiaries-with-a-Substance-Use-Disorder.pdf
  31. https://www.safeproject.us/resource/women/
  32. https://www.samhsa.gov/sbirt
  33. https://c4innovates.com/brsstacs/BRSS-TACS_State-by-State-Directory-of-Peer-Recovery-Coaching-Training-and-Certification-Programs_8_26_2020.pdf
  34. https://ncsacw.acf.hhs.gov/files/peer19_brief.pdf
  35. https://www.kff.org/womens-health-policy/issue-brief/expanding-postpartum-medicaid-coverage/
  36. https://www.montcopa.org/DocumentCenter/View/13037/Recovery-Coaching-Practice-Guidelines?bidId=
  37. Link: https://gasubstanceabuse.org/cares-program/
  38. https://www.cebc4cw.org/program/sobriety-treatment-and-recovery-teams/detailed
  39. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6993963/
  40. https://psycnet.apa.org/record/2021-20460-001
  41. https://elearning.asam.org/products/integrating-recovery-coaches-into-general-medical-settings-1-cme