Implementation of a Neonatal Abstinence Syndrome Weaning Protocol: A Multicenter Cohort Study

Abstract

, on behalf of the OCHNAS Consortium abstract OBJECTIVES: To evaluate the generalizability of stringent protocol-driven weaning in improving total duration of opioid treatment and length of inpatient hospital stay after treatment of neonatal abstinence syndrome (NAS). METHODS:We conducted a retrospective cohort analysis of 981 infants who completed pharmacologic treatment of NAS with methadone or morphine from January 2012 through August 2014. Before July 2013, 3 of 6 neonatology provider groups (representing Ohio's 6 children's hospitals) directed NAS nursery care by using group-specific treatment protocols containing explicit weaning guidelines. In July 2013, a standardized weaning protocol was adopted by all 6 groups. Statistical analysis was performed to identify effects of adoption of the multicenter weaning protocol on total duration of opioid treatment and length of hospital stay at the protocol-adopting sites and at the sites with preexisting protocol-driven weaning.RESULTS: After adoption of the multicenter protocol, infants treated by the 3 groups previously without stringent weaning guidelines experienced shorter duration of opioid treatment (23.0 vs 34.0 days, P , .001) and length of inpatient hospital stay (23.7 vs 31.6 days, P , .001). Protocol-adopting sites also experienced a lower rate of adjunctive drug therapy (5% vs 21%, P = .004). Outcomes were sustained by the 3 groups who initially had specific weaning guidelines after multicenter adoption (duration of treatment = 17.0 days and length of hospital stay = 23.3 days).CONCLUSIONS: 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.WHAT'S KNOWN ON THIS SUBJECT: Use of a standard treatment protocol with stringent weaning guidelines for infants with neonatal abstinence syndrome supports improved outcomes including shorter duration of opioid exposure and length of hospital stay. WHAT THIS STUDY ADDS:We demonstrate generalizability of a protocol-driven weaning strategy for improvement in hospital outcomes for neonatal abstinence syndrome. After adoption, adherent protocol-adopting centers improved outcomes and eliminated differences in outcomes compared with centers with preexisting stringent weaning protocols.

Neonatal Abstinence Syndrome: Update on Diagnostic and Therapeutic Strategies

“…NAS scoring systems may help support the therapeutic decision process . Although substantial scientific efforts have been focused on NAS pharmacologic treatment for years, a clear uniformity in management is still lacking . On the other hand, there is large consensus on avoiding the following specific treatment approaches in relation to their known adverse effects: naloxone (opioid antagonist), which may cause seizures; paregoric (camphorated tincture of opium), which contains a high level of alcohol and other toxic excipients for the neonate; and benzodiazepines (sedatives) and chlorpromazine (antipsychotic), with a long half‐life and associated adverse events …”

“…Pharmacologic characteristics, dosages, and advantages and disadvantages of individual drugs are summarized in Table . Beyond the appropriate drug choice, the use of a standardized protocol for NAS treatment makes a difference in terms of neonatal outcomes . Recently, in the biomedical literature, many NAS treatment algorithms have been proposed .…”

Neonatal abstinence syndrome: an update

“…A multicenter retrospective cohort study from the Ohio NAS research collaborative focused on the implementation of a standardized NAS weaning protocol (31). From 2012 to 2014, 981 infants completed pharmacologic treatment for NAS with methadone or morphine in one of the six children's hospitals in Ohio.…”

The opioid epidemic and neonatal abstinence syndrome in the USA: a review of the continuum of care

“…Though these methods may be subject to error, literature shows that a standardised NAS scoring system is associated with shorter length of stay. A recent multicentre quality improvement initiative showed a reduction in length of stay and length of treatment when practices were standardised 58 59…”