care, 11We selected this timeframe to ensure that we captured literature that best reflects the current state of treatment efforts and the most recent data available on NAS. Page 5 GAO-18-32 Newborn Health Medicaid payment, and recommended practices and challenges related to addressing NAS.12 • We conducted a web-based survey administered to Child Welfare Directors in fifty states and the District of Columbia and included in the survey questions about whether Child Welfare Directors had received federal or state guidance related to NAS. All 51 respondents completed the survey for a response rate of 100 percent. To examine our last audit objective on HHS’s strategy related to addressing NAS, we interviewed agency officials and reviewed documents on the department’s efforts to develop a strategy. Specifically, we interviewed relevant officials from CMS and HHS’s Behavioral Health Coordinating Council concerning their efforts to develop a strategy related to addressing NAS. In reviewing relevant HHS documents, we focused on HHS’s Protecting Our Infants Act Report to Congress, which includes a strategy to address identified gaps, challenges, and recommendations related to NAS and prenatal opioid use. In addition, we reviewed the relevant standards for internal control in the federal government and the relevant criteria from GAO’s body of work on effectively managing performance under the Government Performance and Results Act (GPRA) of 1993 and the GPRA Modernization Act of 2010.13 See appendix I for further details of our methodology related to these objectives. We conducted this performance audit from September 2016 to October 2017 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for 12The Behavioral Health Coordinating Council is a coordinating body within HHS with the goals to share information and identify and facilitate collaborative, action-oriented approaches to address HHS’s behavioral health agenda without duplication of effort across the department. 13Internal control is a process effected by an entity’s oversight body, management, and other personnel that provides reasonable assurance that the objectives of an entity will be achieved. See GAO, Standards for Internal Control in the Federal Government, GAO-14-704G (Washington, D.C.: Sept. 2014). In past reports, we have identified best practices in planning. For example, see GAO, Executive Guide: Effectively Implementing the Government Performance and Results Act, GAO/GGD-96-118 (Washington, D.C.: June 1996), GAO, Combating Terrorism: Evaluation of Selected Characteristics in National Strategies Related to Terrorism, GAO-04-408T (Washington, D.C.: Feb. 3, 2004) and GAO, Health Care Quality: HHS Should Set Priorities and Comprehensively Plan Its Efforts to Better Align Health Quality Measures, GAO-17-5 (Washington, D.C.: October 13, 2016). Page 6 GAO-18-32 Newborn Health our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. NAS is a withdrawal condition within infants that can result from the prenatal use of opioids by pregnant women. Prenatal opioid use occurs when a woman, during the course of her pregnancy, uses an opioidbased medication or substance. Prenatal opioid use can take various forms, including (1) the use of prescriptions for pain management, such as fentanyl and oxycodone; (2) medication-assisted treatment for opioid addiction, such as methadone and buprenorphine; (3) prescription drug misuse or use disorder (such as using an opioid without a prescription, using a different dosage than prescribed, or continuing to use an opioid when it is no longer needed for pain); and (4) illicit opioid use, such as heroin use. These types of prenatal opioid use are not mutually exclusive. A 2014 study found that almost 22 percent of pregnant Medicaid beneficiaries filled a prescription for an opioid during their pregnancy.14 Medication-assisted treatment—an approach that combines the use of certain medications and behavioral therapy—is generally considered by HHS and medical specialty societies to be the standard of care for treating pregnant women with opioid use disorders, depending on the individual and her circumstances.15 SAMHSA and several medical 14Rishi J. Desai et al., “Increase in Prescription Opioid Use During Pregnancy Among Medicaid-Enrolled Women,” Obstetrics and Gynecology, vol. 123, no. 5 (2014). 15In August 2017, the American College of Obstetricians and Gynecologists issued updated guidance noting that medication-assisted treatment continues to be the recommended therapy for pregnant women with opioid use disorders; however, the society recognizes that medically supervised withdrawal can also be considered under the care of a physician experienced in perinatal addiction treatment and with informed consent if a woman does not accept medication assisted treatment. The guidance notes that more research is needed to assess safety, efficacy, and long-term outcomes of medically supervised withdrawal.