Participants summarized their lives with SUD as “a struggle to get help.” Many described past experiences encountering multiple barriers to entering -or staying in recovery programs. Barriers included long waitlists, not being eligible for treatment due to pregnancy, or not having a referral from a provider. One patient recounted her attempt to “be committed” to residential treatment:

Another powerful reminder of what participants were up against in terms of addiction and barriers to receiving help was overdose death. Many had lost family members and friends to drug overdose and grieved the losses, but also the hopeless reality of SUD and dangerous drugs.

The medical records indicate SUN participants’ health and social histories. All participants reported past opioid use, ranging from prescription medications and diverted pain pills to non-prescription synthetic fentanyl and heroin. Two-thirds (66%) used multiple substances in addition to opioids, most commonly amphetamines and marijuana, reflecting the prevalence of polysubstance use among this population. For those who had a documented account of substance use initiation (n = 9), most began using in their teenage years, though some reported being introduced to opioids later in life through medical prescriptions. Further, more than half (59%) disclosed at least one traumatic experience, including physical abuse (31%), sexual abuse (21%), or other forms of trauma (27%). Nearly a quarter (24%) grew up in homes where alcohol or drugs were regularly used. Some noted being introduced to substances at an early age by family members. Many participants also faced involvement with the legal system: 44% reported a history of arrest, incarceration, or other legal challenges, and 14% had survived at least one overdose.

In focus groups, participants consistently indicated pregnancy as the event that prompted them to seek information and medical care, change their substance use behaviors, and/or enter treatment. Many had prior experience with sobriety or SUD treatment. Some expressed being “ready to quit” (2023) for a long time, while others reached a point of wanting treatment after learning about their pregnancy. Regardless of prior motivation, everyone saw pregnancy as a motivator and an opportunity to take steps towards treatment.

To protect their own and their baby’s health, some participants had begun sourcing diverted Subutex (OAT) in their community. This means accessing prescription OAT without a prescription. Although pregnancy was not planned for many participants, all expressed concern for the health of their baby and wished they had “a cheaper, easier route [to buy Subutex] than off of the street.” (2023).

Participants most commonly found the SUN program through a referral from a primary or urgent care provider after disclosing their substance use. A few participants had heard about SUN from community programs or by interacting with other SUD services. Participants indicated that access to SUN was fast and easy. They expressed relief to be able to begin care within days, as explained by a participant:

From medical records, initiation of prenatal care varied, with 41% beginning care during the first trimester and another 41% in the second trimester of pregnancy. The remaining 18% started in the third trimester. A majority (65%) had prior live births, with data missing for 18% of participants.

Survey responses indicate that 90% of participants “strongly agreed” they were able to begin care promptly. The remaining responses were split between “moderately agree” and “strongly disagree,” with a 3% non-response rate. These findings highlight the SUN program’s effectiveness in facilitating timely prenatal care access for pregnant individuals with substance use disorders.

Staff described pregnancy as a crucial “window of opportunity” for initiating recovery. Pregnancy offers a time with heightened motivation and increased contact with health care and social services. The SUN program has the capacity to accept participants immediately, but is still working on a system to track referrals and time-to-initiation (time from first contact to first visit).

Staff are acutely aware of the potential negative health effects of substance use and the risk of return-to-use during pregnancy. Therefore, offering OAT is a crucial part of initiating treatment. Many participants experience polysubstance use, combining opioids with other substances such as cocaine or methamphetamine, for which there are no effective pharmaceutical treatments available. Based on staff experience, providing OAT can reduce the use of other substances, making it essential for facilitating recovery for pregnant individuals with complex substance use histories. To ensure that participants have immediate access to OAT at the correct dose, SUN collaborates with local pharmacies. Federal and state regulations govern the prescribing and dispensing of OATs like methadone and buprenorphine. These regulations can limit the availability of such treatments in certain areas, making collaboration with pharmacies essential to ensure patients have access to necessary medications.

Participants agreed that a powerful and necessary facilitator for them to engage with recovery was having someone who immediately believed in them and communicated “that they are wanted, that they deserve better” (2021). Some pointed to the peer support specialist – someone with lived experience – for giving them assurance and “authentic advice” (2023) during a difficult time. This steadfast support during the ups and downs of early recovery was explained as:

Participants also stressed the facilitating aspects of being in a structured, long-term program. They described the “relief” (2023) of knowing someone would follow them through pregnancy and the postpartum period.

Another key facilitator to staying engaged with recovery was consistently having reliable access to OAT. Participants described past experiences engaging in recovery and still having to source diverted OAT, opioids, or heroin to avoid withdrawal symptoms. During pregnancy, dosing needs change. Participants said they could trust SUN to help them with the prescription changes on short notice.

Participants also described barriers to engagement, including feeling overwhelmed by the initial process at SUN and having to tell their story to multiple people. Some are alone in their recovery journey (without support from friends and family), and a few described being unprepared for the emotional burden of starting treatment. In surveys, 29% of respondents even indicated that “people in their life” limited their ability to access SUN services and support, with one respondent noting: “not everyone in my life can see how the clinic helped me” (2023). These barriers were also reflected in medical records, where a few participants indicated that a partner’s or family member’s active substance use conflicted with their recovery at SUN.

Another concern participants shared was fear of being reported to child welfare services. Many are wary of health care providers and described experiences of feeling judged, reprimanded, or taken advantage of as having created distrust. Fear is therefore quickly evoked by actions or attitudes from staff. A participant described how this fear manifested during one of SUN’s practices:

In the survey write-in section, a few participants made note of not trusting some staff in the SUN program, feeling like staff’s thoughts or ideas were imposed on them, or they were judged for not being on time for their appointment. Further, one participant indicated that they strongly disagreed that they could trust the SUN staff.

The staff expressed a unanimous belief in SUN participants’ recovery success. They have observed what social support and stable OAT treatment can do to someone’s life, but also recognized that it can be a hard transition from street and prescription drugs to OAT. They emphasized the value of having peer support specialists to coach the transition to stable OAT use. The peer support specialists are able to “be straight” (staff interview) with participants because of their own lived experiences (see Tables 4, 5).

Staff emphasize that addressing basic needs—such as transportation, food, housing, and social support—is critical during early recovery. A staff member explained that these needs provide the foundation for participants to remain engaged with OAT and benefit from services that foster long-term stability:

Staff may encounter challenges in communication and case management, particularly during the early stages of recovery. During that time, participants often face social instability, resulting in urgent needs and frequent crises. These situations demand rapid problem-solving and place both practical and emotional strain on staff, who must constantly shift between tasks. A staff member explains:

Staff also see stigma as a consistent barrier to engaging with program-based recovery. They all have experience exhibiting or observing judgment and hostility in their field, and hear participants’ accounts of feeling ashamed and judged. To help counter the damage from stigmatizing experiences, staff emphasized the use of trauma-informed language in all encounters with participants. Still, the pervasive effects of societal stigma toward people with SUD can be difficult to overcome.

Last, like participants, staff described “fear of having baby taken away” (staff interview) as a strong barrier to engaging with treatment. SUN’s social and clinical services are aligned in their goal of keeping families together whenever possible, which, among other practices, is formalized in their use of the federal provision, Plan of Safe Care (POSC). The POSC is a preventative tool aimed at safeguarding infant health by identifying substance-exposed pregnancies. SUN’s staff know that infant and parent health and well-being are intrinsically linked. By meeting basic needs and supporting mental, behavioral, and pregnancy health, they aim to avoid child welfare reporting and custody issues. Staff have seen these measures lead to positive outcomes. Yet, many times, participants’ prior experience with child welfare reports, investigations, and/or having children in out-of-home placement induces such stress that it continues to act as a barrier to engaging with prevention measures for their current pregnancy. Staff recognize the inherent conflict between recovery engagement and the threat of child welfare involvement. Ultimately, social service staff will transition from prevention services to child welfare services, as explained by staff:

Participants expressed the value of working with providers who understand addiction and remain encouraging through the process. They talked about “layers of recovery” (2021), which includes missed appointments, times with slower progress, or return to drug use. Having providers who are non-judgmental and remain supportive is key to continuous treatment engagement, as described by one participant:

When feeling seen and understood, participants said they could be honest about their recovery process and better engage with services and education. They explained that their trust in staff increased when staff were willing to share decision making power and were transparent about changes or challenges to treatment plans. A participant stated:

Access to services such as housing and transportation, plus referrals for mental health and family/parenting support, were described as core to the recovery process. By gaining stability and independence, participants felt empowered to plan longer-term and envision their future as a parent. Working through mental and behavioral health issues was described as a necessary part of the process, as one participant described:

An examination of medical records and participant surveys from the SUN program provides insight into the socioeconomic and health challenges faced by participants and their experiences while receiving services. At the time of enrollment, 21% of participants were employed, with some actively seeking work. More than half (52%) reported one or more social needs, with transportation (31%) and housing (21%) being the most prevalent. The medical notes further highlighted that many participants faced unstable living situations, with housing needs evolving throughout their treatment. Changes included moving in with or separating from family members or partners, or seeking more space for their children. A significant majority (76%) had co-morbidities, with 66% experiencing psychiatric conditions such as depression, anxiety, and bipolar disorder.

Survey responses indicated that 90% of participants “strongly agreed” they were treated with respect within the SUN program. Regarding assistance with social needs: 59% found SUN to be “extremely helpful” in accessing housing resources, while smaller percentages reported it as “moderately helpful” (3%), “slightly helpful” (7%), or “not helpful/help not offered” (18%). In regard to facilitating transportation, 72% indicated that SUN was “extremely helpful,” with others rating it as “moderately” (7%) or “slightly” helpful (3%).

These findings underscore the complex interplay of social determinants and health challenges among SUN participants and highlight the program’s role in addressing these multifaceted needs.

SUD affects all aspects of life, making recovery a process best supported by behavioral interventions, coaching, and skill building help. The staff expect that SUN participants will have setbacks, including late or missed appointments, return to use, and may engage in self-protective mechanisms through what a peer support specialist referred to as“smoke and mirrors” (staff interview). SUN is responsive to the realities of addiction and recovery through the treatment, services, and interventions.

As part of interventions, SUN offers behavioral health support and education to increase social and financial independence. Staff explained that as participants have their basic needs met, they also increase their capacity for receiving coaching and building skills. Each partner uses evidence-based tools and frameworks for intervention and education, and sees great value in having formal approaches. In the social service sector, they primarily utilize coaching techniques emphasizing practical skills such as budgeting and household management to help participants transition into long-term recovery and parenthood:

Within the health care and public health sectors, interventions include individualized behavioral health consultations or educational classes such as birthing, breastfeeding, infant care, and parenting. The curriculum is sometimes tailored to people with SUD, like legal aspects of pain management and giving birth while in recovery:

To ease transitions between treatment, services, and interventions, SUN has established a referral practice that includes both an electronic referral and direct communication between partners. The direct communication happens over the phone or in-person, known as a “warm handoff” (Staff interview). This practice removes the burden from participants to navigate the system and retell their stories.

To further bolster referral practices and communication, SUN also has a monthly care-coordination meeting. Staff described the direct impact of getting all partners together to discuss complex care coordination cases for participants with extended needs. Having “everyone in the room” (Staff interview) can save time by not duplicating efforts or communicating in parallel.

To realize their referral practices and care-coordination meetings, SUN first had to establish a shared agenda and legal framework for exchanging participant information. Formalized and explicit alignment of goals has helped create trust between partners with different areas of expertise. Staff across agencies expressed a mutual understanding of treatment and support to aid participants’ recovery. The POSC, previously introduced in Phase 3, is an example of coordinating care across clinical and social services to anticipate and address risks before delivery in an effort to preserve families. This novel approach has, however, led to conflicts between participants’ recovery goals, monitoring, and reporting mandates. Still, SUN’s staff believed the blueprint they developed to improve collaboration across agency lines has increased SUN’s ability to effectively provide patient-centered care.

Staff also identified organizational barriers that challenge their operations day to day, including constraints on organizational resources. As SUN continues to grow, each of the sectoral partners must plan for staffing and hours that will support the SUN program. Staff explained that it takes time and effort to treat and support people with SUD, and many staff are at capacity in terms of time and emotional availability. A SUN staff member in an administrative role explained:

Another barrier occurs when SUN participants integrate with the (non-SUN) general population, receiving services through a partnering organization or agency (e.g., at the delivery hospital). SUN staff rely on nurses, medical assistants, and receptionists who serve the entire facility, not just the SUN program. Serving SUN participants can be unpredictable and lead to “bottleneck” situations or staff being pulled away from planned tasks. Among those staff not dedicated to SUN participants, this has led to agitation and frustration. As one health care staff member explained:

Participants described the gradual positive changes they experienced because of their recovery and enrollment in the SUN program. They talked about strengthening relationships with family members, regaining custody of children, securing housing, or taking steps towards becoming a peer support specialist. One participant shared how the SUN program helped her reconnect with her mother:

Participants also expressed that recovery is a process and that changing habits takes time. Even when on a good path, they still must actively work towards their recovery goals.

Participants also consistently described that their family’s needs, baby’s health, or “being a good parent” (2021, 2023) were strong motivators for working to maintain recovery. As participants explained:

Participants agreed that the care they received through SUN’s program had set them on a path to long-term recovery. In surveys, most participants (86%) “strongly agreed” that the services and support they received at SUN would help them maintain long term recovery (7% “moderately agreed” and 7% were missing).

Participants expressed the need for ongoing support. Some also talked about their need for community housing with access to residential or mobile OAT treatment. Some expressed a desire for a supportive or group housing situation for women with children. Last, participants suggested that SUN strengthen their approach by including a partnership with domestic violence resources.

Maintaining recovery through SUN was also described as a substantial time commitment, which could present barriers to their continued engagement with treatment. Some wished they could access services closer to home as they transitioned into parenting and work. Time spent on transport and in appointments started to encroach on their life.

When summarizing participants’ engagement, birth-, and recovery outcomes from medical records, 29 participants had completed 204 visits to the SUN clinic (18.4 on average). They engaged with care and services for 4.6 months on average. Among singleton births (n = 30), 87% were born at term (>37 weeks completed gestation), and 80% of infants were not low birth weight (10% were low birthweight and 10% were missing birth weight data). At the time of birth, 94% of delivering participants adhered to treatment (defined as keeping appointments and filling MOUD prescriptions).

When staff reflected on their work supporting SUN’s participants in recovery during pregnancy, they described finding meaning, but also a need for setting boundaries and practicing self-care. Situations in their work (e.g., responding frequently to participants in “crisis”) can be emotionally taxing. Peer support specialists particularly expressed not being able to continue their role long-term. Taking breaks and having time off and with family is very important, as a staff member notes:

To financially sustain a program like SUN, where participants typically need extended services and time in appointments, leadership must either fight for local or state budget allocations or continuously prove their worth to secure grant money. A solution could be to extend Medicaid reimbursement for services related to clinical perinatal and SUD treatment, such as extended appointment time, time with peer support specialists, and breastfeeding support. Staff explain that “sustainability [is only possible with] changing the funding model” (Staff interview), as reimbursements do not currently match the time and resources it takes to support recovery for pregnant people.

Funding is also needed for training staff across the sectoral partners collaborating with the SUN program, like the hospital’s emergency department and neonatal intensive care unit. Staff identify the value in training all staff interacting with SUN participants in managing care for patients with SUD. Trauma and recovery-informed approaches help prevent SUD-related stigma manifest in unsupportive language use, timeliness requirements, and hostile attitudes. Staff explain this could ease integration and improve care for people with SUD.

SUN’s sustainability also depends on strong community ties. Founded in response to local needs, the program was built on professional relationships between healthcare, legal, correctional, and policy sectors. These relationships remain grounded in a shared understanding of the circumstances and social environment that determines health. To maintain community support, SUN staff actively educate decision-makers and local leadership about the realities of long-term recovery and recognize their roles as ongoing advocates and educators.

To support sustained recovery, the Cabarrus County health department opened an additional clinic in 2021 where SUN participants can transition after one year postpartum. This clinic also provides services for participants’ romantic partners and family members in recovery. Despite this progress, housing remains one of the greatest obstacles for former SUN participants to maintain recovery. Staff envisioned expanding the postpartum phase of the SUN program into affordable housing ‘recovery communities’ that integrate services and formal family support.