See Committee on Obstetric Practice and the American Society of Addiction Medicine, “Committee Opinion: Opioid Abuse and Opioid Use Disorder in Pregnancy,” no. 711 (August 2017, replaces committee opinion number 524). Background NAS and Prenatal Opioid Use Page 7 GAO-18-32 Newborn Health specialty societies, including the American College of Obstetricians and Gynecologists and the American Society of Addiction Medicine, have noted that providing medication-assisted treatment during pregnancy prevents complications associated with illicit opioid use, encourages prenatal care, and reduces the risk of obstetric complications.16 Further, women may use multiple substances in addition to opioids during pregnancy—known as maternal polysubstance use—such as tobacco, alcohol, or anti-depressants, among others.17 Experts consider NAS to be an expected and treatable result of women’s prenatal opioid use. Symptoms of NAS usually develop within 72 hours of birth, but may develop anytime in the first 2 weeks of life, including after hospital discharge.18 These symptoms in infants typically include symptoms of opioid withdrawal, such as • irritability, • high-pitched and excessive crying, • stiffness, • sweating, • vomiting, GAO reported in 2015 that the gaps in efforts to address prenatal opioid use and NAS most commonly cited by federal agency officials and experts were related to the treatment of prenatal opioid use and NAS. Agency officials and experts said that there has not been adequate research comparing different types of treatment approaches and that research is needed on how best to treat a pregnant woman with an opioid use disorder so that the treatment is most effective for the woman while offering minimal risk to the fetus. See GAO-15-203. For more information on factors that can affect access to medicationassisted treatment, see GAO, Opioid Addiction: Laws, Regulations, and Other Factors Can Affect Medication-Assisted Treatment Access, GAO-16-833 (Washington, D.C.: Sept. 2016). 16For more information see SAMHSA, “Methadone Treatment for Pregnant Women.” HHS Publication No. (SMA) 14-4124 (Revised 2014) and Committee on Obstetric Practice and the American Society of Addiction Medicine, “Committee Opinion: Opioid Abuse and Opioid Use Disorder in Pregnancy.” 17See Stephen W. Patrick et al., “Prescription Opioid Epidemic and Infant Outcomes,” Pediatrics, vol. 135, no. 5 (2015) and Kendra Grim et al., “Management of Neonatal Abstinence Syndrome from Opioids,” Clinics in Perinatology, vol. 40 (2013). 18The onset of opioid withdrawal, including methadone withdrawal, frequently occurs during the first 12 to 72 hours, but may be delayed for weeks. Because NAS symptoms sometimes take days to appear, the mother and infant may be discharged from the hospital before the infant begins to show withdrawal symptoms. Page 8 GAO-18-32 Newborn Health • diarrhea, • poor feeding, • seizures, and • respiratory distress.19 There is currently no national standard of care for screening or treating NAS. There have been a few scoring tools developed to screen the infant to determine the appropriate course of treatment. Health care providers predominantly diagnose NAS using the Finnegan Neonatal Abstinence Scoring Tool, which calculates a score based on a variety of central nervous, metabolic, respiratory, and gastro-intestinal symptoms that might be observed.20 The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recommend that infants with NAS should not be initially treated with medication, known as pharmacologic treatment. Instead, these organizations recommend starting with non-pharmacologic treatment, which includes placing the infant in a dark and quiet environment, swaddling, breastfeeding, rooming-in with the mother, and providing high-calorie nutrition, among other things. For example, rooming-in—allowing the mother to reside with the infant during the infant’s treatment—may have benefits, such as helping to develop a bond between the mother and infant and to reduce the severity of the infant’s NAS symptoms. Pharmacologic treatment, such as using methadone or morphine, may be necessary only for the relief of moderate to severe signs of NAS. See figure 1 for more information on non-pharmacologic and pharmacologic treatment. 19NAS is also associated with premature birth and lower birth weight and can interfere with the mother-infant bonding process. 20Other available scoring tools used to screen infants for NAS include the Lipsitz Neonatal Drug-Withdrawal Scoring System, the Neonatal Narcotic Withdrawal Index, Neonatal Withdrawal Inventory, and the modified Finnegan scale. Each scoring tool assesses individual NAS symptoms to determine the severity of NAS for purposes of guiding treatment. The tools differ in the items assessed and the score threshold that determines how the infant is treated. For example, infants scoring an 8 or greater on the Finnegan Neonatal Abstinence Scoring Tool are recommended to receive pharmacologic treatment. In contrast, infants who receive a score of four on the Lipsitz scoring system are recommended to receive pharmacologic treatment. For more information about these and other scoring tools, see Lauren M. Jansson et al., “The