that a standard protocol also helps health care providers understand the tools used to assess the severity of NAS; know the types of medication used in treatment, including amounts and duration; and learn how to wean the infant off these medications. Similarly, one article we reviewed noted that infants who were treated at facilities that adopted standard treatment protocols experienced shorter durations of pharmacologic treatment compared with infants who were treated at facilities that did not use a standard protocol.53 50For example, see Lisa Clark and Annie Rohan, “Identifying and Assessing the Substance-Exposed Infant,” MCN in Advance (2015); Walter K. Kraft et al., “Neonatal Abstinence Syndrome: Pharmacologic Strategies for the Mother and Infant” (2016); and Katherine M. Newnam, “The Right Tool at the Right Time: Examining the Evidence Surrounding Measurement of Neonatal Abstinence Syndrome,” Advances in Neonatal Care, vol. 14, no.3 (2014). 51For example, the American Academy of Pediatrics recommends that every facility in the United States adopt a protocol for screening and treating NAS. See Hudak and Tan, American Academy of Pediatrics. “Neonatal Drug Withdrawal.” 52Additionally, officials we interviewed from all of the eight hospital and four non-hospital settings told us they had implemented or planned to implement a protocol for treating infants with NAS. However, health care providers at one hospital in West Virginia told us that while most children’s hospitals likely had established protocols for screening and treating infants with NAS, some newborn nurseries not within children’s hospitals may not have a protocol for screening and treating NAS. As a result, health care providers said, these facilities may not have a standard practice of keeping the infants long enough at the facility to identify withdrawal symptoms if the infants do not begin withdrawing until after discharge. 53Eric S. Hall et al., “Implementation of a Neonatal Abstinence Syndrome Weaning Protocol: A Multicenter Cohort Study,” Pediatrics, vol. 136, no.4 (2015). Page 28 GAO-18-32 Newborn Health Stakeholders we interviewed and literature we reviewed identified several challenges health care providers face in their efforts to address NAS.54 The most frequently cited challenges included (1) the use of multiple substances by pregnant women, which can exacerbate NAS; (2) the stigma faced by women who use opioids during pregnancy, which may affect whether they seek prenatal care to address NAS, among other things; (3) hospital staff burden and limited physical capacity to care for infants with NAS; (4) limited coordination of care for mothers and infants with NAS; and (5) gaps in research and data on NAS. These challenges are described in more detail below. The use of multiple substances by pregnant women, which can exacerbate NAS. Most stakeholders we interviewed and some of the literature we reviewed noted that the use of multiple substances by pregnant women, including opioids—referred to as maternal polysubstance use—can be a challenge, and some stated that the use of these substances can exacerbate NAS symptoms. According to the stakeholders, the substances can include methamphetamines, nicotine, alcohol, cocaine, marijuana, benzodiazepines, and Gabapentin.55 The stakeholders and literature indicated that maternal polysubstance use can lead to multiple conditions in the infant—such as prematurity or Hepatitis C—that can exacerbate NAS symptoms and prolong the length of an infant’s hospital stay. For example, one expert noted that many women with opioid use disorders are also heavy cigarette smokers, and the nicotine typically exacerbates NAS withdrawal symptoms. Additionally, officials from a hospital and non-hospital setting we visited told us that they had developed a separate protocol for treating infants exposed to multiple substances that includes the use of several medications to address the more severe NAS withdrawal symptoms. 54We counted the number of times stakeholders we interviewed cited a challenge to determine the most commonly identified challenges. We included a challenge if at least ten of the 32 stakeholders we interviewed identified it. Many of these challenges are similar to those we have identified in prior work on NAS. See GAO-15-203. 55Gabapentin is an anti-epileptic medication used clinically to address convulsions. Health care providers at several of the facilities in West Virginia that we spoke with told us that it has been used recreationally to boost the effects of illicit opioids while at the same time making the symptoms of NAS substantially worse and more difficult to treat. However, health care providers at one of the facilities told us that it is difficult to test the infant for in utero exposure to this substance. Challenges Faced by Health Care Providers in Addressing NAS Include Maternal Use of Multiple Substances and Stigma Faced by Women Who Use Opioids Page 29 GAO-18-32 Newborn Health Stigma faced by women who use opioids which may affect whether they seek prenatal care to mitigate the severity of NAS, among other things. Most stakeholders we interviewed and several of the literature articles we reviewed noted that the stigma faced by pregnant women with opioid use disorders is a challenge in