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March 12, 2019
Opioid Use and Neonatal Abstinence Syndrome
The prevalence of opioid use disorder (OUD)—problematic
NAS Screening and Treatment
opioid use leading to clinically significant impairment or
No specific NAS screening guideline has been uniformly
distress—among pregnant women has gradually increased
endorsed or adopted in clinical practice. Health care
as the nation’s opioid epidemic has unfolded. This has led
providers typically diagnose NAS using statistically
to increases in several adverse outcomes for infants,
validated scoring tools (e.g., Finnegan Neonatal Abstinence
including neonatal abstinence syndrome (NAS). Recent
Scoring Tool) that score severity based on observed
efforts by both Congress and the U.S. Department of Health
symptoms in the infant. Medical literature points to the
and Human Services (HHS) have focused on addressing the
importance of hospitals and nurseries adopting standard
rising rate of NAS.
screening protocols, as well as properly training staff on the
correct use of validated scoring tools.
NAS is a withdrawal syndrome that often occurs when
newborns no longer receive a substance, such as an opioid,
NAS is a treatable condition that may require both
that was administered in utero. According to a 2014
pharmacologic (e.g., methadone) and non-pharmacologic
Pediatrics article focusing on opioid use and NAS, NAS
care (e.g., gentle handling and feeding on demand).
symptoms can occur within 24 to 72 hours of birth and may
According to a 2017 Government Accountability Office
last up to several months, depending on the type of opioid
(GAO) report, there is no national standard of care for NAS
exposure (e.g., heroin, methadone, or buprenorphine). Such
treatment. However, the American Academy of Pediatrics
symptoms can include tremors, feeding and sleeping
(AAP), a professional organization of pediatricians,
difficulties, temperature instability, and hyperirritability.
recommends that infants with NAS should initially be
While other substances (e.g., alcohol) have been associated
treated with non-pharmacologic care, as pharmacologic
with NAS, opioids are one of the most common substances
treatment may be necessary only for severe cases. In
associated with this syndrome.
addition, multiple research studies highlight the importance
of involving mothers during treatment. The AAP further
According to a 2018 Centers for Disease Control and
recommends that case management services (which assist
Prevention (CDC) analysis, the national prevalence (new
the infant and caregiver in obtaining necessary medical,
and existing cases) of OUD during pregnancy increased
educational, and other services) can ensure that quality care
from 1.5 OUD cases per 1,000 hospital births in 1999 to 6.5
is provided within each treatment stage.
OUD cases per 1,000 hospital births in 2014. New cases
(incidence) of NAS have also increased over a similar time
Gaps in Research on Screening and Treatment
period. From a national perspective, a 2012 JAMA study
Several recent reports have identified a lack of research on
found that the incidence rate of NAS has increased
standardized, uniform screening tools and treatment
significantly, from 1.2 cases per 1,000 hospital births per
protocols. In 2016, the Eunice Kennedy Shriver National
year in 2000 to 3.4 cases per 1,000 hospital births per year
Institute of Child Health and Human Development
in 2009. However, the incidence rate of NAS has varied by
(NICHD) at the National Institutes of Health (NIH) held a
state (see Figure 1). These select data are among the most
workshop with invited experts to review research gaps on
recent national and state-level estimates available.
opioid use in pregnancy, NAS, and childhood outcomes.
Figure 1. Incidence Rate of NAS per 1,000 Hospital
The workshop proceedings cited gaps specific to NAS,
Births in 25 States, 2012 and 2013
including the need for more objective screening tools and
the most effective types of non-pharmacologic and
pharmacologic therapies to use in different clinical
scenarios. In 2017, HHS highlighted similar research gaps
in screening tools and treatment protocols, including the
need for further development of objective screening tools
and how exposure to different opioid types and/or other
substances during pregnancy may affect the severity and
treatment of NAS.
According to a 2015 GAO report that examined federally
funded research on prenatal drug use, executive agency
officials and experts also cited NAS screening and
Source: Ko et al., 2016, “Incidence of Neonatal Abstinence
treatment research gaps. Reasons for these gaps included
Syndrome – 28 States, 1999-2013,” MMWR.
difficulties conducting research among pregnant women
Note: 2013 incidence rates are reported, except 2012 data reported
with substance use disorders, as well as other research areas
for four states (Maine, Maryland, Massachusetts, and Rhode Island)
beyond prenatal drug use receiving funding priority (the
without 2013 data.
report did not specify these other areas).
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Opioid Use and Neonatal Abstinence Syndrome
Select Health Outcomes Among Infants
As required by the Comprehensive Addiction and Recovery
with NAS
Act of 2016 (CARA; P.L. 114-198), a 2017 GAO report
examined NAS in the United States and related treatment
At a joint 2016 workshop with invited experts in the field,
services under Medicaid. According to GAO, the strategy
NIH found a lack of evidence about the long-term health
HHS outlined in its Final Strategy report does not have a
effects of prenatal opioid exposure and NAS.
comprehensive, organized method to address the demands
Since that time, a few academic research articles have
of treating NAS. Specifically, GAO stated that the strategy
examined short- and long-term health outcomes among
lacks priorities, timeframes, and responsibilities for
infants with and without NAS, respectively. These articles
implementing HHS’s proposed recommendations for
suggest that infants with NAS are susceptible to
addressing NAS. While HHS agreed with GAO’s
assessment, it noted that implementation of the strategy was
hospital readmission within the first five years of life,
contingent upon funding.
delayed developmental milestones and higher rates of
strabismus (crossed eyes) by the age of two, and
Provisions in the SUPPORT for Patients
poor academic performance in secondary schooling.
and Communities Act of 2018
Addressing NAS
In October 2018, Congress enacted the Substance Use–
HHS’s Role in Addressing NAS
Disorder Prevention that Promotes Opioid Recovery and
HHS is addressing NAS through data and surveillance,
Treatment (SUPPORT) for Patients and Communities Act
research and evaluation, programs and services, and
of 2018 (P.L. 115-271). The SUPPORT Act is intended to
education activities in its respective agencies. These
address extensive overprescribing and misuse of opioids in
agencies include CDC, the Administration for Children and
the United States, building upon previous legislative efforts
Families (ACF), the Centers for Medicare and Medicaid
that were also intended to help address, in part, the opioid
Services (CMS), the Health Resources and Services
epidemic (e.g., CARA and the 21st Century Cures Act [P.L.
Administration (HRSA), and the Substance Abuse and
114-255]). Provisions in the SUPPORT Act relevant to
Mental Health Services Administration (SAMHSA). CDC
NAS took a variety of approaches to address the issue, and
generally conducts surveillance of OUD among pregnant
are broadly summarized below.
women and NAS. SAMHSA largely focuses on addressing
Section 1005 requires HHS to issue guidance to
prenatal substance use among pregnant women and
improve care for infants with NAS and their families,
recovery services for mothers, as evidenced by a recently
and requires GAO to conduct a study addressing gaps in
released clinical guidance for treating pregnant and
Medicaid coverage for pregnant and postpartum women
parenting women with OUD. ACF and HRSA largely focus
with a substance use disorder.
on services for infants and children affected by prenatal
substance use, including NAS.
Section 1007 adds a state option to make Medicaid
inpatient or outpatient services available to infants with
CMS oversees Medicaid, a federal-state health care
NAS at a residential pediatric recovery center.
program that finances health care coverage for diverse
groups of low-income populations, including children,
Sections 7061-7064 require HHS, among other things,
pregnant women, adults, individuals with disabilities, and
to conduct and disseminate research on NAS, provide an
people aged 65 and older. As reported to Congress by the
update on the implementation of and funding or
Medicaid and CHIP Payment and Access Commission
additional authorities needed for its strategy to address
(MACPAC), Medicaid covered almost half of all births in
NAS, and develop and promote educational materials
the United States in 2014, and according to 2018 Pediatrics
about pain management and prevention of substance use
article, Medicaid covered 82% of NAS-related births in
disorders during pregnancy.
2014. In light of Medicaid’s importance in addressing NAS,
Section 7151 allows SAMHSA-funded Building
CMS released an informational bulletin for states in June
Communities of Recovery grants to focus outreach
2018 that discusses Medicaid’s role and limitations in NAS
activities on NAS.
diagnosis and treatment, as well as Medicaid reimbursable
treatment design approaches states may wish to pursue.
Select Issues for Congress
Congress may consider prioritizing research on the
HHS’s Strategy to Address NAS
standardization of screening and treatment, as well as long-
The Protecting Our Infants Act (P.L. 114-91) was enacted
term health outcomes associated with NAS. Congress may
in November 2015. It required HHS, among other things, to
also consider expanding availability and coverage of
conduct a review of its planning and coordination activities
different NAS treatments through Medicaid or other
related to prenatal opioid use (including NAS), develop a
programs. Finally, Congress may consider monitoring
strategy to address gaps in research and federal programs,
HHS’s efforts to address NAS, including potential costs
and submit a report to Congress on the findings of the
associated with these efforts.
review and the related strategy. After seeking public
comment about its initial strategy, HHS released a final
report in June 2017, Protecting Our Infants Act: Final
Victoria R. Green, Analyst in Health Policy
Strategy (Final Strategy). This Final Strategy report
IF11133
provides HHS’s recommendations to address and expand
on NAS prevention, treatment, and services activities
administered by the department.
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Opioid Use and Neonatal Abstinence Syndrome
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