Neonatal Abstinence Syndrome

Excerpt

During pregnancy, substance abuse is on the rise, especially opioids, both prescribed and illicit, resulting in a hidden epidemic of neonatal abstinence syndrome (NAS). NAS is diagnosed every 25 minutes in the United States. It is a multisystemic disorder resulting from chronic in-utero exposure and its abrupt cessation at birth. The predominant symptoms include central nervous system (CNS), gastrointestinal (GI), and autonomic manifestations. The pathophysiology of this condition remains unknown. Multiple neonatal and maternal factors affect the expression of symptoms, including gestational age, sex, genetics, and maternal polysubstance abuse or smoking. The diagnosis is made based on an accurate maternal history and neonatal clinical features, with or without biological testing. Multiple assessment tools exist, but the traditional Finnegan scoring system is the most commonly used to evaluate neonates and make management decisions. Non-pharmacological care, like rooming-in and control of environmental factors, is the first clinical management strategy and should continue even after discharge from the hospital. Breastfeeding should be strongly encouraged unless there is maternal polysubstance abuse or maternal medical contraindication. When withdrawal signs are severe, pharmacotherapy is initiated. Although no clear consensus exists on which medication is best, morphine remains the most commonly used first-line agent.

More recent evidence supports methadone or buprenorphine to treat NAS as their use is associated with shorter hospital stays and decreased pharmacologically treated days. Phenobarbital and clonidine are useful as second-line agents with variable effects. A standardized approach to both non-pharmacological and pharmacological treatment is essential. A new management approach called "eat, sleep, and console" is based on the basic functioning of the infant, standardized non-pharmacological care, and an increase in the family's involvement in the care of the baby. This approach is showing promising results.

Management of NAS must also address maternal issues such as coexisting mental illness, intimate partner violence, and limited healthcare access to maintain the mother-infant relationship necessary for the infant's normal development. NAS is associated with long-term consequences, including but not limited to neurodevelopmental delays, behavioral problems, and, when untreated, death. Adequate data still lacks long-term outcomes attributed to NAS because of the existence of multiple uncontrollable confounding factors. A public health approach is necessary to reduce the incidence of NAS and the resultant economic burden.

Mainstreaming Addiction Treatment (MAT) Act

The Mainstreaming Addiction Treatment (MAT) Act provision updates federal guidelines to expand the availability of evidence-based treatment to address the opioid epidemic. The MAT Act empowers all health care providers with a standard controlled substance license to prescribe buprenorphine for opioid use disorder (OUD), just as they prescribe other essential medications. The MAT Act is intended to help destigmatize a standard of care for OUD and will integrate substance use disorder treatment across healthcare settings.

As of December 2022, the MAT Act has eliminated the DATA-Waiver (X-Waiver) program. All DEA-registered practitioners with Schedule III authority may now prescribe buprenorphine for OUD in their practice if permitted by applicable state law, and SAMHSA encourages them to do so. Prescribers who were registered as DATA-Waiver prescribers will receive a new DEA registration certificate reflecting this change; no action is needed on the part of registrants.

There are no longer any limits on the number of patients with OUD that a practitioner may treat with buprenorphine. Separate tracking of patients treated with buprenorphine or prescriptions written is no longer required.

Pharmacy staff can now fill buprenorphine prescriptions using the prescribing authority's DEA number and does not need a DATA 2000 waiver from the prescriber. However, depending on the pharmacy, the dispensing software may still require the X-Waiver information in order to proceed. Practitioners are still required to comply with any applicable state limits regarding the treatment of patients with OUD. Contact information for State Opioid Treatment Authorities can be found here: https://www.samhsa.gov/medicationassisted-treatment/sota.