Neonatal abstinence syndrome: transitioning methadone-treated infants from an inpatient to an outpatient setting

Abstract

Background Each year in the US approximately 50,000 neonates receive inpatient pharmacotherapy for the treatment of neonatal abstinence syndrome (NAS). Objective To compare the safety and efficacy of a traditional inpatient only approach with a combined inpatient and outpatient methadone treatment program. Design/Methods Retrospective review (2007-9). Infants were born to mothers maintained on methadone or buprenorphine in an antenatal substance abuse program. All infants received methadone for NAS treatment as inpatient. Methadone weaning for the traditional group (75 pts) was inpatient while the combined group (46 pts) was outpatient. Results Infants in the traditional and combined groups were similar in demographics, obstetrical risk factors, birth weight, GA and the incidence of prematurity (34 & 31%). Hospital stay was shorter in the combined than in the traditional group (13 vs 25d; p < 0.01). Although the duration of treatment was longer for infants in the combined group (37 vs 21d, p<0.01), the cumulative methadone dose was similar (3.6 vs 3.1mg/kg, p 0.42). Follow-up: Information was available for 80% of infants in the traditional and 100% of infants in the combined group. All infants in the combined group were seen ≤ 72 hours from hospital discharge. Breast feeding was more common among infants in the combined group (24 vs. 8% p<0.05). Following discharge there were no differences between the two groups in hospital readmissions for NAS. Prematurity (<37w GA) was the only predictor for hospital readmission for NAS in both groups (p 0.02, OR 5). Average hospital cost for each infant in the combined group was $13,817 less than in the traditional group. Conclusions A combined inpatient and outpatient methadone treatment in the management of NAS decreases hospital stay and substantially reduces cost. Additional studies are needed to evaluate the potential long term benefits of the combined approach on infants and their families.

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

“…Close follow-up and other safety measures may also mitigate potential safety threats for a select subset of patients. 22 Even among control sites with preexisting group-specific protocols, improvements were observed during the multicenter adoption phase. Among control sites, there was a significant reduction in treatment with multiple opioids, indicating failed weans.…”

“…The long-term implications of prolonged opioid treatment on neurocognitive development are not well understood, and appropriate safeguards and transition models must be implemented before the administration of opioid weans with limited clinical supervision. [20][21][22][23] Concerns about providing morphine or methadone to opiate-addicted parents may be unfounded because the average infant dose is reportedly ,0.2% of the average maternal dose. 21 Nevertheless, social work assessment may aid in the selection of appropriate candidate families to receive treatment in the outpatient setting.…”

Neonatal Abstinence Syndrome

“…146 However, morphine treatment also prolongs the length of hospital stay. 147 Incremental increase or decrease of the dose of morphine depending on the severity of withdrawal is often a common practice. 46,143 Because morphine has short half-life, it must be provided every 3 to 4 hours.…”

129: Neonatal outcomes following in utero exposure to buprenorphine/naloxone or methadone

“…25,27 BF initiation rates for the methadone-treated women observed here are similar to that reported elsewhere. 19,27 Prior to our study, information regarding BF during buprenorphine/naloxone treatment was limited to three women reported by Debelak et al 16 and Lund et al 17 The low BF initiation rate among buprenorphine/naloxone-treated mothers seems to relate to the low intention to breastfeed declared by them upon arrival to labor and delivery. After all, intention to breastfeed is considered the strongest predictor of BF initiation.…”

“…Inpatient management was similar among all infants over the study period; however, a subgroup of infants were treated using a combined inpatient/outpatient NAS weaning protocol. 19 Cumulative methadone dose was defined as the total number of milligrams (mg) of methadone the infant received during inpatient hospitalization and if applicable, inpatientoutpatient combined treatment. Methadone to morphine equivalency was calculated based on previously published dosing recommendations.…”