Neonatal Abstinence Syndrome (NAS)/Neonatal Opioid Withdrawal Syndrome (NOWS) Resources

This section contains current resources for NAS/NOWS. If you have any suggestions for any materials that could be added, please let staff know at wispqc@perinatalweb.org.

General Information and Resources
Resource(s) Comments
Definitions and Measures This document gives definitions used to guide data collection.
Key Driver Diagram This is the driver diagram for the NAS/NOWS initiative.
Standardized Algorithm This is the standardized algorithm. Click here to download the risk assessment tool.

 

Getting Started
Resource(s) Comments
Always Events Toolkit
 Always Events(R) are defined as those aspects of the care experience that should always occur when patients, their family members or other care partners, and service users interact with health care professionals and the health care delivery system. A one page overview is also available.
Institute for Healthcare Improvement (IHI) The Institute for Healthcare Improvement (IHI), an independent not-for-profit organization based in Boston, Massachusetts, is a leading innovator, convener, partner, and driver of res​ults in health and health care improvement worldwide. At its core, IHI believes everyone should get the best care and health possible.
IHI has a commitment to Person- and Family-Centered Care. This page lists resources for getting started.
Model for Improvement This page includes a link to a free 90-minute course, “QI 102: How to Improve with the Model for Improvement.”
PDSA Worksheet This worksheet is a component of IHI’s QI Essential Toolkit. The Plan-Do-Study-Act (PDSA) cycle is a useful tool for documenting a test of change. Use this worksheet for each change you test.
QI Project Charter The QI Project Charter provides a rationale and roadmap for team to clarify thinking about what needs to be done and why.
Walk-through Walk-throughs enable providers to understand the experience of care from the patient’s and family’s points of view by going through the experience themselves.

 

Equity

This section contains references that describe some of the disparities and inequities associated with opioid use disorder. It is intended to stimulate thinking on the factors that can affect disparities and inequities for women and infants.

Resource Comments
Abraham AJ, Adams GB, Bradford AC, Bradford WD. County-level access to opioid use disorder medications in Medicare Part D (2010-2015). Health Serv Res. 2019;54(2):390-398. This study used data from Medicare Part D Prescription Drug Event Standard Analytic File (2010-2015) to examine county-level access to OUD medication prescribers.
Andrilla CHA, Moore TE, Patterson DG, Larson EH. Geographic Distribution of Providers with a DEA Waiver to Prescribe Buprenorphine for the Treatment of Opioid Use Disorder: A 5-Year Update. J Rural Health. 2019;35(1):108-112. This study summarizes the geographic distribution of waivered physicians, nurse practitioners, and physician assistants at the end of 2017 and compares it to the distribution of waivered physicians five years earlier.
Friedman J, Kim D, Schneberk T, Bourgois P, Shin M, Celious A, Schringer DL. Assessment of Racial/Ethnic and Income Disparities in the Prescription of Opioids and Other Controlled Medications in California. JAMA Intern Med. 2019 Feb 11. This population-based study used records from California’s prescription drug monitoring program (2011-2015).
Gaither JR, Gordon K, Crystal S, Edelman EJ, Kerns RD, Justice AC, Fiellin DA, Becker WC. Racial disparities in discontinuation of long-term opioid therapy following illicit drug use among black and white patients. Drug Alcohol Depend. 2018;192:371-376. This study, using electronic medical records from the Veteran’s Affairs hospital, to determine whether opioids were discontinued within 60 days of a positive urine drug test.
Haight SC, Ko JY, Tong VT, Bohm MK, Callaghan WM. Opioid Use Disorder Documented at Delivery Hospitalization — United States, 1999–2014. MMWR Morb Mortal Wkly Rep. 2018; 67(31):845-849. This study used hospital discharge data from the 1999-2014 Healthcare Cost and Utilization Project to describe U.S. national and state-specific trends in opioid use disorder documented at delivery hospitalization.
Mack KA, Jones CM, Ballesteros MF. Illicit Drug Use, Illicit Drug Use Disorders, and Drug Overdose Deaths in Metropolitan and Nonmetropolitan Areas–United States. MMWR Surveill Summ. 2017; 66(19):1-12. This study examined changing demographics in drug overdose deaths between 1999 and 2015.
Wyatt R, Laderman M, Botwinick L, Mate K, Whittington J. Achieving Health Equity: A Guide for Health Care Organizations. IHI White Paper. Cambridge, MA: Institute for Healthcare Improvement; 2016. This paper offers practical advice, executable steps, and a conceptual framework that can guide any health care organization in charting its own journey to improved health equity.
Satisfaction Evaluations/Surveys
Resource Comments
Patient satisfaction survey This survey was designed to capture parent/family satisfaction in several key areas. It is currently available online, but we could create a PDF version if needed.

 

Screening Tools for Women
Resource(s) Comments
Committee Opinion No. 711: Opioid Use and Opioid Use Disorder in Pregnancy. Committee on Obstetric Practice (ACOG). Obstet Gynecol. 2017;130(2):e81-e94. Obstetric care providers need to be knowledgeable about the medical, social, and legal consequences that can accompany opioid use by pregnant women. Pregnancy provides an important opportunity to identify and treat women with substance use disorders. Identifying patients with substance use disorders using validated screening tools, offering brief interventions, and referring for specialized care, as needed, are essential elements of care. Additionally, it is important to advocate for this often-marginalized group of patients, particularly in terms of working to improve availability of treatment and to ensure that pregnant women with opioid use disorder who seek prenatal care are not criminalized. Finally, obstetric care providers have an ethical responsibility to their pregnant and parenting patients with substance use disorder to discourage the separation of parents from their children solely based on substance use disorder, either suspected or confirmed.
4Ps Plus https://www.ntiupstream.com/4psabout/
Prevalence of illicit drug use in pregnant women in a Wisconsin private practice setting. Schauberger CW, Newbury EJ, Colburn JM, Al-Hamadani M. AJOG. 2014;211(3):e1-4. Adding 5 questions about drug or alcohol use to the obstetric intake questionnaire proved sensitive in identifying patients with high risks of having a positive drug screen. Conclusion: Enhanced screening should be performed to identify patients using illicit drugs in pregnancy to improve their care.
Screening for Prenatal Substance Use: Development of the Substance Use Risk Profile-Pregnancy Scale. Yonkers KA, Gotman N, Kershaw T, Forray A, Howell HB, Rounsaville BJ. Obstet Gynecol. 2010:116(4):827-833.

The Substance Use Risk Profile-Pregnancy scale is simple and flexible with good sensitivity and specificity. The Substance Use Risk Profile-Pregnancy scale can potentially detect a range of substances that may be abused.

Click here to download a PDF of the scale.
Screening for alcohol and drug use during pregnancy. Chang G. Obstet Gynecol Clin North Am. 2014;41(2):205-12. This article highlights currently available tools to identify prenatal alcohol and drug use and their limitations.
Depression screening
Authorization to Use and Disclose Health Information
Resource Comments
Authorization to Use and Disclose Health Information This authorization template was designed to facilitate communication between obstetric care providers and opioid treatment centers. This authorization complies with HIPAA, Wisconsin law, and federal law 42 CFR Part 2 (governing the use and disclosure of alcohol and drug abuse treatment records).
42 CFR Part 2 In 2010, the HHS Substance Abuse and Mental Health Services Administration (SAMHSA) and the HHS Office of the National Coordinator (ONC) published FAQs “Applying the Substance Abuse Confidentiality Regulations to Health Information Exchange (HIE).”
Prescription Drug Monitoring Program (ePDMP)

Resource Comments
https://pdmp.wi.gov/ By providing valuable information about controlled substance prescriptions that are dispensed in the state, it aids healthcare professionals in their prescribing and dispensing decisions. The ePDMP also fosters the ability of pharmacies, healthcare professionals, law enforcement agencies, and public health officials to work together to reduce the misuse, abuse, and diversion of prescribed controlled substance medications.
https://pdmp.wi.gov/statistics The WI ePDMP Statistics Dashboard provides interactive data visualizations about the controlled substance prescriptions dispensed in Wisconsin, the law enforcement reports submitted to the WI ePDMP, and the use of the WI ePDMP by healthcare professionals and others.
https://pdmp.wi.gov/training-materials This page contains FAQs, including how to register delegates.
Biological Testing for Women with Opioid Use Disorder
Resource Comments
Committee Opinion No. 711: Opioid Use and Opioid Use Disorder in Pregnancy. Committee on Obstetric Practice (ACOG). Obstet Gynecol. 2017;130(2):e81-e94. Routine urine drug screening is controversial for several reasons. A positive drug test result is not in itself diagnostic of opioid use disorder or its severity. Urine drug testing only assesses for current or recent substance use; therefore, a negative test does not rule out sporadic substance use. Also, urine toxicology testing may not detect many substances, including synthetic opioids, some benzodiazepines, and designer drugs. False-positive test results can occur with immune-assay testing and legal consequences can be devastating to the patient and her family. Health care providers should be aware of their laboratory’s test characteristics and request that confirmatory testing with mass spectrometry and liquid or gas chromatography be performed as appropriate.
Specific tests available Tests should include buprenorphine and methadone
Rationale for a Standardized Algorithm
Resource Comments
Hudak ML, Tan RC, Committee on Drugs, Committee on Fetus and Newborn, American Academy of Pediatrics. Neonatal Drug Withdrawal. Pediatrics. 2012;129(2):e540-560. Neonatal Drug Withdrawal
Asti L, Magers JS, Keels E, Wispe J, McClead RE. A Quality Improvement Project to Reduce Length of Stay for Neonatal Abstinence Syndrome. Pediatrics. 2015 Jun 1;135(6):e1494–500. The most effective interventions that impacted LOS for infants with NAS were the development of a staff NAS education program and the implementation of a standard treatment protocol. The formation of the NAS Taskforce was also essential because it facilitated communication and the dissemination of vital treatment information among all clinical staff.
Holmes AV, Atwood EC, Whalen B, Beliveau J, Jarvis JD, Matulis JC, et al. Rooming-In to Treat Neonatal Abstinence Syndrome: Improved Family-Centered Care at Lower Cost. Pediatrics. 2016 Jun;137(6). pii: e20152929. A coordinated, standardized NAS program safely reduced pharmacologic therapy, LOS, and hospital costs. Rooming-in with family and decreased use of NICU beds were central to achieved outcomes.
Neonatal Screening Tools
Resource Comments
Finnegan Neonatal Abstinence Scoring Tool
Assessment of Neonatal Abstinence Syndrome: Tools for Newborn Nursery Staff This WAPC-hosted Webinar was presented on July 24, 2013.
Neo Advances (inter-observer reliability program for the Finnegan) https://www.neoadvances.com/index.html
Lipsitz Scoring Tool
Franck LS, Harris SK, Soetenga DJ et al. The Withdrawal Assessment Tool-Version 1 (WAT-1): an assessment instrument for monitoring opioid and benzodiazepine withdrawal symptoms in pediatric patients. Pediatr Crit Care Med. 2008;9(6):573-580. Withdrawal Assessment Tool-Version 1 (WAT-1)
Lucas K, Knobel RB. Implementing Practice Guidelines and Education to Improve Care of Infants with Neonatal Abstinence Syndrome. Advances in Neonatal Care. 2012;12(1):40-45. Evidence-based clinical practice guidelines and education around NAS and the FNAST equip caregivers with the necessary tools to consistently and accurately assess an infant with NAS when using the FNAST.

 

Neonatal Biological Testing
Resource Comments
Detection of Drug-Exposed Newborns. Wabuyele SL, Colby JM, McMillin GA. Ther Drug Monit. 2018 Apr;40(2):166–85.
  • Urine
  • Meconium
  • Umbilical cord
Breastfeeding/Human Milk Feeding
Resource Comments
Hudak ML, Tan RC, Committee on Drugs, Committee on Fetus and Newborn, American Academy of Pediatrics. Neonatal Drug Withdrawal. Pediatrics. 2012;129(2):e540-560. Breastfeeding and the provision of expressed human milk should be encouraged if not contraindicated for other reasons.
Schiff DM, Wachman EM, Philipp B, Joseph K, Shrestha H, Taveras EM, Parker MGK. Examination of Hospital, Maternal, and Infant Characteristics Associated with Breastfeeding Initiation and Continuation Among Opioid-Exposed Mother-Infant Dyads. Breastfeed Med. 2018 May;13(4):266-274. Policies for using mother’s milk

Examples of policies

Currently, there are no universally accepted policies addressing breastfeeding/use of breast milk for women who test positive for illicit substances. The attachments below are examples of the policies used in some institutions based on interpretations of the current evidence. The Learning Collaborative will continue to follow the growing body of evidence.

 
Non-Pharmacological Strategies
Resource Comments
Eat Sleep Console (ESC) Eat Sleep Console
McKnight S, Coo H, Davies G, Holmes B, Newman A, Newton L, et al. Rooming-in for Infants at Risk of Neonatal Abstinence Syndrome. Am J Perinatol. 2015 Nov 20;  

 

Medication Protocols
Resource Comments
Hall ES, Wexelblatt SL, Crowley M, Grow JL, Jasin LR, Klebanoff MA, et al. Implementation of a Neonatal Abstinence Syndrome Weaning Protocol: A Multicenter Cohort Study. Pediatrics. 2015 Oct;136(4):e803-10. Adoption of a stringent weaning protocol resulted in improved NAS outcomes, demonstrating generalizability of the protocol-driven weaning approach. Opportunity remains for additional protocol refinement.
Hall ES, Wexelblatt SL, Crowley M, Grow JL, Jasin LR, Klebanoff MA, et al. A Multicenter Cohort Study of Treatments and Hospital Outcomes in Neonatal Abstinence Syndrome. Pediatrics. 2014 Aug;134(2):e527-34. Use of a stringent protocol to treat NAS, regardless of the initial opioid chosen, reduces the duration of opioid exposure and length of hospital stay. Because the major driver of cost is length of hospitalization, the implications for a reduction in cost of care for NAS management could be substantial.
Examples The Learning Collaborative will post examples of medication protocols.
Developmental Follow-Up
Resource Comments
Smith VC, Wilson CR, COMMITTEE ON SUBSTANCE USE AND PREVENTION. Families Affected by Parental Substance Use. Pediatrics. 2016 Aug;138(2). pii: e20161575.

Children whose parents or caregivers use drugs or alcohol are at increased risk of short- and long-term sequelae ranging from medical problems to psychosocial and behavioral challenges. Pediatricians need to know how to assess a child’s risk in the context of a parent’s substance use. The purposes of this clinical report are to review some of the short-term effects of maternal substance use during pregnancy and long-term implications of fetal exposure; describe typical medical, psychiatric, and behavioral symptoms of children and adolescents in families affected by substance use; and suggest proficiencies for pediatricians involved in the care of children and adolescents of families affected by substance use, including screening families, mandated reporting requirements, and directing families to community, regional, and state resources that can address needs and problems.

 
Chasnoff IJ, Gardner S. Neonatal abstinence syndrome: a policy perspective. J Perinatol. 2015 Aug;35(8):539–41. Follow-up: provide ongoing developmental and behavioral screening and oversight for the child, ensuring access to earliest interventions as needed. In the majority of cases, these services can be covered through federal Early Periodic Screening, Diagnosis and Treatment funds. Strengthen collaborations between clinical providers, community agencies, home visiting programs and state agencies to track substance-exposed infants and their families through early childhood.
Oei JL, Melhuish E, Uebel H, Azzam N, Breen C, Burns L, et al. Neonatal Abstinence Syndrome and High School Performance. Pediatrics. 2017 Feb;139(2). pii: e20162651. A neonatal diagnostic code of NAS is strongly associated with poor and deteriorating school performance. Parental education may decrease the risk of failure. Children with NAS and their families must be identified early and provided with support to minimize the consequences of poor educational outcomes.

 

Wisconsin State Law
Resource Comments
Wisconsin Statute, Chapter 146.0255. Testing infants for controlled substances or controlled substance analogs. https://docs.legis.wisconsin.gov/statutes/statutes/146
Other Resources
Resource Comments
WAPC Newborn Withdrawal Project Educational Toolkit

This compendium of educational materials is intended for both parents and health care providers of newborns experiencing neonatal abstinence syndrome (NAS) and pregnant women undergoing methadone maintenance treatment (MMT) or other treatments for opioid use disorder.
Assessment and Intervention in the Home: Women and Infants Affected by Opioids This tool is intended for anyone who may provide care in the home to women or infants affected by opioids.
A Blueprint for Action: Improving Care for Women and Infants Affected by Opioids The blueprint is a document from which stakeholders can collaborate and coordinate efforts to improve care for women and infants affected by opioids. It identifies six areas for change that are intended to focus on major areas that can improve care of women and infants and lead to better outcomes.
From Just Say No to Just Say Know (and Do) This document was developed to describe a framework for comprehensive care of women with opioid use disorder. It is intended for stakeholders committed to improving the care for women with opioid use disorder.
Vermont Oxford Network
American Academy of Pediatrics Resources
American College of Obstetricians and Gynecologists. Committee Opinion No. 524. Opioid Abuse, Dependence, and Addiction in Pregnancy.  Committee Opinion No. 524. Opioid Abuse, Dependence, and Addiction in Pregnancy