Psych CASC / OSCE · Addiction psychiatry — perinatal substance use
Explain OAT and NAS in pregnancy — CASC communication station
MRCPsych/FRANZCP-style communication station: non-punitive explanation of OUD in pregnancy, OAT rationale, NAS as expected/treatable, reject forced detox, outline postpartum safety plan.
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Target exams
Station brief
Format. Communication station, approximately 7–10 minutes after reading. You are the psychiatry/addiction registrar. The examiner may play the patient and/or her mother. [3]
Candidate instructions. Explain why medication treatment (OAT) is recommended in pregnancy. Contrast forced detox with methadone/buprenorphine. Explain neonatal abstinence in plain language without stigma. Address child-protection fears honestly. Agree a collaborative plan including postpartum continuity. [2][3][4]
Candidate scenario
She meets criteria for severe OUD, is 20 weeks pregnant, and is considering buprenorphine induction today. Mother insists medication is “another drug” and wants two-week detox only. [5]
Marking domains
- Empathy, structure, non-stigmatising language
- Accurate plain-language model of OUD and pregnancy risks of untreated use
- Explains OAT as medical treatment that stabilises mother and fetus
- Explains NAS as expected, time-limited, treatable — not lifelong addiction or automatic removal
- Rejects unsafe forced detox with clear rationale
- Child-protection transparency without threats
- Postpartum plan (continue OAT, naloxone, supports)
- Checks understanding / teach-back [1][3][4]
Reveal assessor key
Open. Name role and time; ask patient and mother top fears (baby removal, “addiction to buprenorphine,” family shame). [4]
Explain OUD in pregnancy. “This is a medical condition where opioids take over despite harm. In pregnancy we care for two patients — you and the baby. Street opioids bring overdose, infection, and unstable blood levels that stress the pregnancy.” [3]
Explain OAT. “Medicines like buprenorphine or methadone steady opioid receptors, cut craving and chaotic use, and are recommended instead of forced detox in pregnancy. They are treatment, not a moral failure.” Name that maintenance agonists are evidence-supported.[2][5]
Buprenorphine practicalities. “We start when you are already withdrawing a bit so the first dose does not knock other opioids off too fast. Typical start is a small under-the-tongue dose (for example 2–4 mg), then build toward a daily dose that stops withdrawal (often 8–24 mg).” Link to clinic and antenatal team.[5]
NAS myth-bust. “Some babies show temporary withdrawal — shaky, hard to settle, feeding fuss — after any opioid including treatment medicines. Neonatal teams expect this, score it, and treat it. It is not the same as the baby being ‘addicted for life,’ and it is not automatic proof you cannot parent.” Mention supportive care and possible short medicine treatment for the baby.[1][4]
Two-week detox pressure. Acknowledge mother’s wish for a quick clean start. Explain risks of withdrawal for the pregnancy and high chance of return to street use with overdose risk. Offer support for the family crisis without colluding in unsafe detox.[2][3]
Child protection. “We work openly with safeguarding when needed to keep babies safe — engagement in care and a stable plan usually help, not hurt. Hiding and avoiding antenatal care is more dangerous.” Avoid inventing statute numbers. [4]
Close. Summarise plan: OAT start/follow-up, antenatal scans, take-home naloxone, alcohol/tobacco advice if relevant, early postpartum review, written info, teach-back. [3][5]
References
- [1]Jones HE, Kaltenbach K, Heil SH, et al. Neonatal abstinence syndrome after methadone or buprenorphine exposure N Engl J Med, 2010.PMID 21142534
- [2]Minozzi S, Amato L, Jahanfar S, et al. Maintenance agonist treatments for opiate-dependent pregnant women Cochrane Database Syst Rev, 2020.PMID 33165953
- [3]American College of Obstetricians and Gynecologists Committee Opinion No. 711 Summary: Opioid Use and Opioid Use Disorder in Pregnancy Obstet Gynecol, 2017.PMID 28742670
- [4]Klaman SL, Isaacs K, Leopold A, et al. Treating Women Who Are Pregnant and Parenting for Opioid Use Disorder and the Concurrent Care of Their Infants and Children: Literature Review to Support National Guidance J Addict Med, 2017.PMID 28406856
- [5]American Society of Addiction Medicine The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update J Addict Med, 2020.PMID 32511106